Severe metallosis following total knee arthroplasty: a case report and review of radiographic signs

Severe metallosis following catastrophic failure of total shoulder arthroplasty - a case report

Metallosis is an unusual but consequential complication arising from orthopedic hardware implantation, characterized by the deposition of metallic particles in the periprosthetic soft tissues. The incidence of metallosis associated with shoulder arthroplasties is exceptionally rare since the shoulder is not a weight-bearing joint, making it less susceptible to mechanical wear and, consequently, to conditions like particle disease and metallosis. Nevertheless, anomalous metal-on-metal interactions can develop in total shoulder arthroplasties if the polyethylene component fails due to wear, fracture, or dissociation. If left unaddressed, metallosis can incite an adverse immune-mediated local tissue response, culminating in joint destruction and adjacent soft tissues and muscle necrosis. In this case report, the diagnosis of metallosis was made in a patient with an anatomic total shoulder arthroplasty using a state-of-the-art photon counting detector CT supplemented by post-processing metal artifact reduction algorithms. This advanced imaging approach was effective in discerning the source of implant failure and in identifying manifestations of severe metallosis including osteolysis and pseudotumor formation. Advanced imaging methods can accurately characterize the severity and extent of metallosis, thereby helping guide surgical planning to mitigate serious complications associated with this condition.

Extensive Metallosis in a Primary Knee Arthroplasty as a Result of Polyethylene Wear: Is It Avoidable?

Metallosis is known to occur in metal-on-metal arthroplasty and has been of concern to orthopaedic surgeons worldwide. It is a rare, late complication of total knee arthroplasty (TKA), in which metal-on-metal contact leads to metal debris deposition in the surrounding tissue. Reasons for metal-on-metal contact could range from wear of the polyethylene insert to abnormal joint biomechanics. Many components can affect the development of metallosis, with polyethylene wear being the most common cause of metallosis. This paper discusses the case of an 85-year-old man who developed metallosis, attributed to polyethylene wear, 24 years after undergoing TKA. It also highlights the different components of knee prostheses, evaluates the efficacy of different types of polyethylene, and explores whether ceramic coating can improve TKA outcomes and reduce complications such as metallosis.

A Rare Case of Metallosis Co-occurring With Chronic Prosthetic Joint Infection in Total Hip Arthroplasty

Prosthetic joint infection (PJI) and metallosis are known complications of total hip arthroplasty (THA) and are causes for revision surgeries. Articulating metal surfaces in total hip arthroplasty with corrosion at modular junctions can lead to the release of metal ions that can cause an immune-mediated biological reaction. There are few cases in the literature of both coinciding together. We describe a case of chronic Cutibacertium acnes PJI and metallosis co-occurring in a 64-year-old female after THA with a dual mobility construct. After undergoing uncomplicated left THA through a modified Hardinge approach, the patient dislocated anteriorly after four weeks and required revision of her acetabular component to a less anteverted position. Nine months later, she presented with hip pain and was found to have medial wall fragmentation and cystic changes around the greater trochanter on radiographs, elevated serum cobalt and chromium levels, and a benign noninfected hip aspiration. During her revision procedure, intraoperative histopathology showed over 20 neutrophils per high power field in multiple samples and fluid aspirates demonstrating Gram-positive rods. She was also found to have pseudotumor formation with the erosion of the anterior and posterior capsules with black debris on the femoral stem trunnion and the backside of the modular dual mobility liner. An antibiotic spacer was placed and her cultures grew into C. acnes. She completed six weeks of intravenous ceftriaxone and, during her "drug holiday," she dislocated her spacer and was found to have a lateral femoral diaphyseal stress fracture at the distal end of her spacer. She underwent stage II of her revision, and while the plan was to continue her antibiotics, she had an adverse reaction and was transitioned to oral antibiotics for six months. Due to delayed healing, she underwent additional irrigation and debridement with head and liner exchange. Her wound then healed, and at her one-year final follow-up, she was able to ambulate without pain, and her serum inflammatory and metal ion levels were within normal limits. Concurrent PJI and metallosis from articulating metal interfaces can occur, and a high index of suspicion is necessary to properly manage both conditions.

Impact of perivascular lymphocytic infiltration in aseptic total knee revision

AIMS

A limited number of investigations with conflicting results have described perivascular lymphocytic infiltration (PVLI) in the setting of total knee arthroplasty (TKA). The purpose of this study was to determine if PVLI found in TKAs at the time of aseptic revision surgery was associated with worse clinical outcomes and survivorship.

METHODS

A retrospective review was conducted on 617 patients who underwent aseptic TKA revision who had histological analysis for PVLI at the time of surgery. Clinical and radiological data were obtained pre- and postoperatively, six weeks postoperatively, and then every year thereafter.

RESULTS

Within this cohort, 118 patients (19.1%) were found to have PVLI on histological analysis. Re-revision was performed on 83 patients (13.4%) with no significant differences in all-cause or aseptic revisions between groups. A higher incidence of PVLI was noted in female patients (p = 0.037). There was no significant difference in improvement in the range of motion (p = 0.536), or improvement of KSC (p = 0.66), KSP (p = 0.61), or KSF (p = 0.3) clinical outcome scores between PVLI and no PVLI sub-groups. There was a higher incidence of a preoperative diagnosis of pain in the PVLI group compared with patients without PVLI (p = 0.002) present.

CONCLUSION

PVLI found on large-scale histological analysis in TKAs at aseptic revision surgery was not associated with worse clinical outcomes or rates of re-revision. Cite this article: Bone Joint J 2021;103-B(6 Supple A):145-149.

Metallosis after knee replacement: a review

INTRODUCTION

Although metallosis is a well-known complication after total hip arthroplasty, little is known about this phenomenon after total (TKA) or unicompartmental knee arthroplasty (UKA). The aim of the present work was to review the current knowledge about the reasons and the diagnostic as well as therapeutic management of metallosis after knee arthroplasty.

MATERIALS AND METHODS

A literature search was performed through PubMed until April 2019. Search terms were "metallosis" in combination with "knee", "knee prosthesis", "knee arthroplasty" and "knee replacement", respectively. All publications were analyzed regarding publication year, level of evidence, number of knees/patients treated, type of prosthesis, metallosis cause, time period between primary implantation and metallosis emergence, laboratory examination, treatment, complications and follow up.

RESULTS

A total of 38 studies reporting on a total of 97 knees were identified. 29 studies reported on metallosis after TKA, 8 after UKA, and one study after both procedures. The time period between the primary implantation and metallosis emergence ranged between 6 weeks and 26 years. The most common reason was the failure of a metal-backed patellar component in 40%, followed by implant/structural- and PE failure (wear/dislocation) in 27% and 18% of the cases, respectively. Complete blood cell count, serum chemistry, erythrocyte sedimentation rate or C-reactive protein serum values were not indicative to diagnose metallosis. The diagnosis was confirmed by histopathological analyses and macroscopic evaluation during surgery. Depending on the particular cause various surgical procedures have been performed. Complete prosthesis exchange was the most common one showing no complications in 89.4% of the cases.

CONCLUSIONS

Metallosis after knee arthroplasty is a rare and perhaps underestimated or under published complication. A systematic diagnostic approach is necessary for the timely and correct diagnosis. A thorough debridement as well as a (sub)total synovectomy should be always performed. In cases with a damaged component, a partial/complete prosthesis exchange leads to the best results. Should a malalignment be the cause of the metallosis, then it should be corrected within the revision surgery.

Pseudotumors and High-Grade Aseptic Lymphocyte-Dominated Vasculitis-Associated Lesions Around Total Knee Replacements Identified at Aseptic Revision Surgery: Findings of a Large-Scale Histologic Review

BACKGROUND

Aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) development (including pseudotumors) secondary to metal debris generation around total hip arthroplasties is a well-recognized histopathologic phenomenon. Emerging data have highlighted a similar potential concern around TKAs although the body-of-knowledge has largely been limited to individual case reports or small retrospective case series. This study sought to establish the prevalence of pseudotumors or high-grade ALVALs seen at the revision of primary TKAs and to establish the correlation between histologic ALVAL grade and patient-reported functional outcome measures.

METHODS

The findings of 321 non-infective (aseptic) patients undergoing unilateral revision knee surgery, at a high-volume tertiary referral center, were reviewed. Each case was independently histologically classified. Complete patient-reported functional outcome measures were available for 134 patients (42%) allowing correlation between functional performance and histopathology results.

RESULTS

Five distinct pseudotumors and a further 18 high-grade ALVALs were histologically identified representing 1.6% and 5.6% of the cohort, respectively. When compared by histologic grade, Oxford Knee Score and Western Ontario and McMaster University's Osteoarthritis Index suggested a high correlation between ALVAL grade and functional knee scores.

CONCLUSION

These findings suggest a prevalence of pseudotumors or high-grade ALVALs at revision TKA surgery of >7%. This unexpectedly high result may contribute insight into the previously under-appreciated significance of metal debris-related local tissue reactions around TKAs. The findings also demonstrate a strong near-linear inverse relationship between patient-reported clinical knee performance and the underlying histologic grade of local tissue reaction. These results have potential management implications for patients with underperforming TKAs and should prompt consideration of an ALVAL secondary to metallosis in the differential diagnosis.

LEVEL OF EVIDENCE

This is a retrospective cohort study with Level III evidence.

Is There Material Loss at the Conical Junctions of Modular Components for Total Knee Arthroplasty?

BACKGROUND

Clinical concern exists regarding fretting corrosion and material loss from taper junctions in orthopedic devices, with previous research focusing on the modular components from total hip arthroplasty. Comparatively little has been published regarding the fretting corrosion and material loss in modular knee devices. The purpose of this study is to evaluate fretting corrosion damage and quantify material loss for conical total knee arthroplasty taper interfaces.

METHODS

Stem tapers of 166 retrieved modular knee devices were evaluated for fretting corrosion using a semiquantitative scoring method. High precision profilometry was then used to determine volumetric material loss and maximum wear depth for a subset of 37 components (implanted for 0.25-18.76 years). Scanning electron microscopy and energy-dispersive X-ray spectroscopy were used to characterize the observed damage.

RESULTS

Mild to severe fretting corrosion was observed on the majority of tapers, with 23% receiving a maximum visually determined damage score of 4. The median rate of volumetric material loss was 0.11 mm³/y (range 0.00-0.76) for femoral components (both cone and bore taper surfaces combined) and 0.01 mm³ (range 0.00-8.10) for tibial components. Greater rates of material loss were associated with mixed metal pairings. There was a strong correlation between visual fretting corrosion score and calculated material loss (ρ = 0.68, P < .001). Scanning electron microscopy revealed varying degrees of scratching, wear, fretting corrosion, and instances of cracking with morphology not consistent with fretting corrosion, wear, or fatigue.

CONCLUSION

Although visual evidence of fretting corrosion damage was prevalent and correlated with taper material loss, the measured volumetric material loss was low compared with prior reports from total hip arthroplasty.

Elusive Differential of a Painful Unstable Total Knee Arthroplasty - Metal on Cement Disease

Particle disease from the release of metal, cement, ceramic, or polyethylene particles is a rare condition in total knee replacement. Wear, fracture, or corrosion of the components leads to foreign body reaction in the joint, followed by pain, swelling, limited motion, difficulty in walking, functional disability, and occasional systemic disease. This paper presents two cases of metal-on-cement disease as an etiology for the implant failure wherein the metal particles were shed off from the implant, along with cement and polyethylene particles, leading to a complex foreign body reaction in the failed total knee. We have coined this phenomenon as "cementallosis." Initial symptoms and signs from implant failure in both patients were mild, intermittent mediolateral knee pain that was aggravated after walking but no pain at rest or at night. The pain was associated with a 'buckling' sensation, recurrent knee swelling, and gradually worsening knee range of motion. Clinical examination in both cases was suggestive of a well-healed anterior midline surgical scar, mild to moderate effusion, mild diffuse tenderness over the entire joint, limited functional range of motion, grade 1+ laxity throughout the range of motion, and intact distal neurovascular status. Routine blood and synovial fluid workup were inconclusive for identifying the exact etiology of the patient's symptoms. Radiographs, computed tomography (CT) scans, as well as bone scans, were negative for prosthetic joint infection, component malalignment, polyethylene wear, maltracking, or loosening of the components but showed mild to moderate effusions, synovial hypertrophy, and mild scattered periprosthetic osteolysis. Intraoperatively, there was significant synovial hypertrophy with dark pigment deposition and apparent dissociation of the femoral and tibial components from the underlying cement mantle, although the cement was well-adhered to the underlying bone. Synovial fluid and multiple tissue specimens were suggestive of complex foreign body granulomas with metal, cement, and polyethylene particles. These patients had undergone surgery by the same surgery team in the community using the same implant. These cases demonstrate the failure of a total knee arthroplasty implant at the metal-cement interface with features of adverse local tissue reactions that resemble a pseudotumor from the metal-on-metal disease in the knee joint. We have compared and contrasted the clinical presentations, laboratory, imaging, histopathological, and intraoperative study findings in these cases. Knowing what to look for will aid in early diagnosis, ordering necessary investigations, better surgery planning, reducing operative time, as well as improving outcomes and cost of care. The aim of this paper is to educate the audience about this new phenomenon as a cause of knee prosthesis failure produced by a complex pseudotumor-like foreign body reaction that involves metal, cement, and polyethylene particles.

Ultrasonographic and radiographic findings of polyethylene component displacement with severe metallosis and metal-induced synovitis following total knee arthroplasty

Aseptic loosening and wear is second to only infection as the most common cause of arthroplasty failure. Degeneration of the polyethylene and metal arthroplasty components can lead to metallosis, which can cause a combination of direct cytotoxic effects and an inflammatory response within the synovial and periarticular tissues. This can result in bone resorption and secondary arthroplasty component loosening as well as a metal containing joint effusion and metal-induced synovitis. Little literature exists as to the ultrasonographic findings of metal-induced synovitis and polyethylene component displacement. As the use of musculoskeletal ultrasound significantly increases, being aware of these findings is important. The most important ultrasonographic findings include differentiating a joint effusion from synovitis utilizing dynamic compression, identifying areas of echogenic shadowing related to metal deposition and visualizing displaced arthroplasty components. The following is a case report that demonstrates the ultrasonographic imaging findings of metallosis, metal-induced synovitis and polyethylene component displacement. We will also demonstrate the ultrasound-guided aspiration findings as well as radiographic and gross pathologic correlations.

Metallosis in cemented titanium alloy total knee arthroplasty without apparent metal-on-metal articulation

BACKGROUND

Metallosis is an uncommon phenomenon observed in late failures of cemented total knee arthroplasty (TKA), and it is rarely seen in the absence of metal-on-metal articulation.

METHODS

We report the case of a TKA patient with cemented titanium-alloy components and a polyethylene patella that was revised for early loosening with intra-operative severe metallosis.

RESULTS

We found that loosening and severe metallosis were associated with methacrylate particle abrasion on titanium alloy surfaces.

CONCLUSION

Serum titanium ion level measurement may be helpful in the workup of a painful TKA with titanium-alloy components in order to establish a diagnosis.

The Sequelae of Metallosis Resulting in Skin Pigmentation and Tattooing: A Case Presentation and Literature Review

With advancing technologies in orthopedics and increasing demands of the population for orthopedic interventions, younger patients are now receiving joint replacements. One of the potential risks of joint replacement is metallosis, or the local and systemic release of metal ions. Metallosis is caused by the release of metallic debris, secondary to hardware failure. The phenomenon is most commonly associated with failed metal-on-metal hip prostheses and is characterized locally by heavy staining of surrounding soft tissue, metallic synovitis, joint effusion, and gradual loosening of the prosthesis. Additionally, metallic debris can also lead to periarticular superficial skin manifestations. The release of metal ions has further been known to lead to systemic upsets including neurologic deficit (declining vision, hearing, or cognition; headaches), cardiac failure, and hypothyroidism. As the number of patients seeking major orthopedic interventions grows, the incidence of metallosis-related skin tattooing will also increase. The structural components of a failed joint replacement can be revised (improving patients' pain and functioning). However, any skin tattooing secondary to metallosis presents the treating dermatologist with clinical challenge, due to lack of research regarding treatment of this condition. Our aim is to review the published literature on metallosis, including the pathophysiology. After assessing publications on the treatment of traumatic and cosmetic tattooing, we hope to stimulate further research regarding treatment. This article should also serve to remind orthopedic surgeons that with increasing patient concern regarding cosmesis, a multispecialty approach including referral to a dermatologist is valuable.

Metallosis Presenting as Knee Pain 26 years after Primary Total Knee Arthroplasty

INTRODUCTION

Metallosis occurs when periprosthetic soft tissues, synovium, and/or bone is infiltrated by metallic debris secondary to metal-on-metal wear. This debris can cause a chronic inflammatory reaction leading to joint instability, pain, and swelling, and may cause osteolysis, implant looseningand ultimately implant failure.

CASE REPORT

An 81 year old female, with a history of primary left total knee arthroplasty, presented with a 6 month history of left knee pain, swelling, and limited range of motion following a fall. Radiographs and joint aspiration were performed, with results that showed no evidence of periprosthetic trauma or infection but were suspicious for chronic metallosis. The patient underwent revision total knee replacement of the left knee which revealed extensive necrotic black metal debris throughout the joint space. Histopathology confirmed the diagnosis of a foreign body reaction consistent with metallosis.

CONCLUSION

This case is a rare example of chronic metallosis presenting 26 years following total knee replacement. Treatment with revision total knee replacement is the consensus management choice to avoid further destruction of the bone and joint capsule that can occur with metal-induced inflammation.