1
|
Zhong Q, Pan X, Chen Y, Lian Q, Gao J, Xu Y, Wang J, Shi Z, Cheng H. Prosthetic Metals: Release, Metabolism and Toxicity. Int J Nanomedicine 2024; 19:5245-5267. [PMID: 38855732 PMCID: PMC11162637 DOI: 10.2147/ijn.s459255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/13/2024] [Indexed: 06/11/2024] Open
Abstract
The development of metallic joint prostheses has been ongoing for more than a century alongside advancements in hip and knee arthroplasty. Among the materials utilized, the Cobalt-Chromium-Molybdenum (Co-Cr-Mo) and Titanium-Aluminum-Vanadium (Ti-Al-V) alloys are predominant in joint prosthesis construction, predominantly due to their commendable biocompatibility, mechanical strength, and corrosion resistance. Nonetheless, over time, the physical wear, electrochemical corrosion, and inflammation induced by these alloys that occur post-implantation can cause the release of various metallic components. The released metals can then flow and metabolize in vivo, subsequently causing potential local or systemic harm. This review first details joint prosthesis development and acknowledges the release of prosthetic metals. Second, we outline the metallic concentration, biodistribution, and elimination pathways of the released prosthetic metals. Lastly, we discuss the possible organ, cellular, critical biomolecules, and significant signaling pathway toxicities and adverse effects that arise from exposure to these metals.
Collapse
Affiliation(s)
- Qiang Zhong
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Xin Pan
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Yuhang Chen
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Qiang Lian
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Jian Gao
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Yixin Xu
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Jian Wang
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Zhanjun Shi
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Hao Cheng
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| |
Collapse
|
2
|
Freund SS, Thorn APJ, Puri A, Petersen MM, Baad-Hansen T. Elevated cobalt levels in metal-on-polyethylene knee megaprostheses: a prospective 1-year cohort study of 56 patients with hip and knee megaprostheses. Acta Orthop 2024; 95:174-179. [PMID: 38629902 PMCID: PMC11022749 DOI: 10.2340/17453674.2024.40502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/13/2023] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND AND PURPOSE Concerns have emerged regarding elevated levels of cobalt and chromium in patients with metal-on-metal megaprostheses. This prospective study aims to identify systemic cobalt and chromium levels in metal-on-polyethylene knee and hip megaprostheses and their associations with other factors. METHODS 56 patients underwent knee or hip megaprosthesis surgery at 2 sarcoma centers. Serum cobalt and chromium levels were measured preoperatively and thrice within the first year using inductively coupled plasma mass spectrometry. RESULTS A statistically significant difference in serum cobalt levels (1.4 ppb; 95% confidence interval [CI] 0.0-3.3) was observed 1 year after knee megaprosthesis surgery compared with preoperative levels. In contrast no difference in chromium levels was observed after 1 year compared with preoperative levels (0.05 ppb; CI 0.0-0.8). An association between younger age, higher eGFR, and increased cobalt levels was observed. No significant correlations were found between ion levels and resection length or the number of modular connections. CONCLUSION We found elevated serum ion levels in metal-on-polyethylene knee megaprostheses in contrast to metal-on-polyethylene hip megaprostheses. Furthermore, a positive correlation between cobalt and chromium levels, and between cobalt and eGFR was identified, along with a negative correlation between cobalt and age. This study highlights the importance of monitoring systemic cobalt and chromium levels in patients with megaprostheses.
Collapse
Affiliation(s)
| | - Andrea Pohly Jeppesen Thorn
- Musculoskeletal Tumor Section of the Department of Orthopedic Surgery, Rigshospitalet - University of Copenhagen, Denmark
| | - Ajay Puri
- Orthopedic Oncology, Tata Memorial Centre, HBNI, Mumbai, India
| | - Michael Mørk Petersen
- Musculoskeletal Tumor Section of the Department of Orthopedic Surgery, Rigshospitalet - University of Copenhagen, Denmark
| | | |
Collapse
|
3
|
Wu D, Bhalekar RM, Marsh JS, Langton DJ, Stewart AJ. Periarticular metal hypersensitivity complications of hip bearings containing cobalt-chromium. EFORT Open Rev 2022; 7:758-771. [PMID: 36475551 PMCID: PMC9780614 DOI: 10.1530/eor-22-0036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hip joints with bearings composed of cobalt-chromium alloy (metal-on-metal bearings) have been one of the most widely used implants in joint replacement arthroplasty. Unfortunately, these implants can contribute to a complication called aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL), a type IV metal hypersensitivity response around the joint. Consistent with such bearings, increased metal debris can be found in the surrounding fluids and in remote tissues and organs, due to wear and corrosion. It is hypothesized that metal ions released from the prosthesis (including Co2+) can potentially form haptens with proteins such as serum albumin in synovial fluid that in turn elicit ALVAL. Generally, elevated cobalt and chromium levels in synovial fluids may indicate implant failure. However, such measurements cannot be used as a reliable tool to predict the onset of ALVAL. To detect ALVAL, some diagnostic tests, questionnaires and imaging techniques have been used clinically with some success, but a standardized approach is lacking. At present, guidelines for implant usage and patient management are ambiguous and inconsistent across health care authorities. To reduce and better manage the development of ALVAL, further research into the precise molecular mechanism(s) by which ALVAL develops is urgently needed. Identification of diagnostic and prognostic biomarkers for ALVAL is required, as are more standardized guidelines for surgery and patient management.
Collapse
Affiliation(s)
- Dongmei Wu
- School of Medicine, University of St. Andrews, St. Andrews, Fife, United Kingdom
| | - Rohan M Bhalekar
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, United Kingdom
| | - Jordan S Marsh
- School of Medicine, University of St. Andrews, St. Andrews, Fife, United Kingdom
| | - David J Langton
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, United Kingdom
| | - Alan J Stewart
- School of Medicine, University of St. Andrews, St. Andrews, Fife, United Kingdom,Correspondence should be addressed to A J Stewart;
| |
Collapse
|
4
|
Systemic Metal Ion Concentrations in Patients With Hip and Knee Megaprostheses: A Prospective Cohort Study. Arthroplast Today 2022; 18:191-201.e1. [PMID: 36561551 PMCID: PMC9764025 DOI: 10.1016/j.artd.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/03/2022] [Accepted: 08/09/2022] [Indexed: 12/13/2022] Open
Abstract
Background Local tissue and serum metal ions have been shown to be elevated in some metal-on-metal and metal-on-polyethylene joint replacements. Local elevations have been linked to adverse local tissue reactions in some patients, and systemic elevation has been less commonly implicated cardiac and neurologic issues. Using a prospective study design, we aimed to identify the changes in serum metal ion levels after hip or knee megaprosthesis reconstruction. Furthermore, we will evaluate the occurrence of adverse effects and complications, possibly linked to metal ion elevation. Methods Fourteen consecutive patients receiving a Modular Universal Tumor Revision System megaprosthesis were enrolled. Blood samples were collected preoperatively and postoperatively to determine the serum ion concentrations of aluminum, chromium, cobalt, and silver. To evaluate the safety of the megaprostheses and the subsequently possible related (elevated) serum metal ion concentrations, all adverse effects and complications were registered until last outpatient clinic visit at the time of this study. Results Compared to the preoperative median serum concentrations, the postoperative median serum concentrations of chromium, silver, and cobalt increased 11-fold, 62-fold, and 64-fold, respectively. The median serum concentration of aluminum increased with 16%. Elevations were primarily noted in patients with knee prostheses. Eight patients had no adverse effects or complications during the period between preoperative and postoperative blood sampling. One adverse effect directly related to the serum metal ion concentrations, namely argyria, was observed. Conclusions This study documents significantly elevated concentrations of the metal ions, but only one adverse effect directly related to the metal ion concentrations was observed. Future studies are needed to further assess the impact of elevated metal ion levels after megaprostheses, specifically knee implants, which are metal-on-metal.
Collapse
|
5
|
Gramlich Y, Hofmann L, Kress S, Ruckes C, Kemmerer M, Klug A, Hoffmann R, Kremer M. Critically high metal ion levels found in metal-on-metal modular hinged knee arthroplasty : a comparison of two different systems. Bone Joint J 2022; 104-B:376-385. [PMID: 35227095 DOI: 10.1302/0301-620x.104b3.bjj-2021-0492.r2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS This study compared the cobalt and chromium serum ion concentration of patients treated with two different metal-on-metal (MoM) hinged total knee arthroplasty (TKA) systems, as well as a titanium nitride (TiN)-coated variant. METHODS A total of 63 patients (65 implants) were treated using either a MoM-coated (n = 29) or TiN-coated (n = 7) hinged TKA (GenuX mobile bearing, MUTARS; Implantcast, Germany) versus the BPKS (Brehm, Germany) hinged TKA (n = 27), in which the weight placed on the MoM hinge is diffused through a polyethylene (PE) inlay, reducing the direct load on the MoM hinge. Serum cobalt and chromium ion concentrations were assessed after minimum follow-up of 12 months, as well as functional outcome and quality of life. RESULTS No differences in mean age (69 years, 40 to 86), mean age adapted Charlson Comorbidity Index (3.1 (SD 1.4)), mean BMI (29.2 kg/m2 (SD 5.8)), or number of other implants were observed between groups. Significant improvements in outcome scores and pain levels were achieved for all groups, and there was no difference in quality of life (12-Item Short-Form Health Survey questionnaire (SF-12)). Mean cobalt and chromium ion levels were significantly higher for the GenuX versus the BPKS hinged TKA (GenuX vs BPKS: cobalt: 16.3 vs 9.4 µg/l; chromium: 9.5 vs 5.2 µg/l). The TiN-coated implants did not appear to confer improvement in the metal ion levels. Metal ion concentrations above 7 µg/l were detected in 81%(29/36) of GenuX patients versus 41% (11/27) in the BPKS group. No GenuX patients had normal levels under 2 µg/l, versus 22% of BPKS patients. No significant reduction in outcome scores was observed regardless of the metal ion levels, whereas higher work-related activity was correlated with higher chromium concentrations. CONCLUSION Hinged TKA, using MoM hinges, resulted in critically high cobalt and chromium ion concentrations. The BPKS hinged TKA showed significantly lower metal ion concentrations compared with the GenuX TKA. No benefits were observed using TiN coating. The different weightbearing mechanics might influence the wear of the component materials. Higher workloads and physical activity could influence chromium levels. Cite this article: Bone Joint J 2022;104-B(3):376-385.
Collapse
Affiliation(s)
- Yves Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Line Hofmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Sandra Kress
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Studies, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Matthias Kemmerer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Alexander Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Michael Kremer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| |
Collapse
|
6
|
Postler A, Beyer F, Lützner C, Tille E, Lützner J. [The use of knee prostheses with a hypoallergenic coating is safe in the medium term : A randomized controlled study]. DER ORTHOPADE 2021; 51:660-668. [PMID: 34734297 PMCID: PMC9352637 DOI: 10.1007/s00132-021-04186-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND In Germany, patients with contact allergy to implant components usually receive coated joint arthroplasties. Whether the treatment using these hypoallergenic implants achieves comparable results to standard treatment with implants consisting of cobalt-chromium alloy (CoCr) implants is controversially discussed internationally and has rarely been investigated in the mid-term. OBJECTIVES Are there differences in blood metal ion concentrations, knee function, and patient-reported outcomes (PROM) between coated and standard implants? MATERIAL AND METHODS 118 patients were randomized to receive either a coated or a standard implant. Knee function as well as patient-reported outcome measures were assessed. Metal ion concentrations in blood samples were additionally determined for chromium, cobalt, molybdenum, and nickel, preoperatively, one and five years after surgery. RESULTS After five years, it was possible to analyse the results of 97 patients. In metal ion concentrations, as well as PRO, consistently good results were seen, without any difference between the groups. While in 13 patients there was an increase in chromium concentration above 2 µg/l one year after surgery, there was no measured value above 1 µg/l after five years. CONCLUSION In our study, similar mid-term results were detected for coated (TiNiN) and standard (CoCr)TKA. With respect to metal ion concentrations and PRO there are no disadvantages in using coated TKA.
Collapse
Affiliation(s)
- Anne Postler
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
| | - Franziska Beyer
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Cornelia Lützner
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Eric Tille
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Jörg Lützner
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| |
Collapse
|
7
|
Roy ME, Whiteside LA, Ly KK, Gauvain MJ. Cobalt-chromium femoral components developed scratches and released metal debris in simulated wear whereas ceramic femoral components did not. Bone Joint J 2021; 103-B:94-101. [PMID: 34053284 DOI: 10.1302/0301-620x.103b6.bjj-2020-2429.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS The aims of this study were to evaluate wear on the surface of cobalt-chromium (CoCr) femoral components used in total knee arthroplasty (TKA) and compare the wear of these components with that of ceramic femoral components. METHODS Optical profilometry was used to evaluate surface roughness and to examine the features created by the wear process in a knee wear simulator. We developed a method of measuring surface changes on five CoCr femoral components and quantifying the loss of material from the articular surface during the wear process. We also examined the articular surface of three ceramic femoral components from a previous test for evidence of surface damage, and compared it with that of CoCr components. RESULTS We found that the surface roughness of CoCr components rapidly increased during the first 1,000 wear cycles, then reached a steady state, but material loss from the surface continued at a rate of 1,778,000 μm3 per million cycles as carbides were removed from its matrix. These carbides formed third-body wear particles, leading to the formation of new scratches even as older scratches were worn away. In contrast, no scratching, loss of material, or other surface damage, when evaluated with one nanometer resolution, was found on the surface of the ceramic components after a 15 M wear cycle test. CONCLUSION This study showed wear and loss of CoCr material from scratching and microabrasive wear in TKA. The material loss from the surface continued in a linear relationship with increasing cycles. We also found the absence of scratching and roughening of ceramic femoral components in simulated wear, suggesting an advantage in wear rate and avoiding metal sensitivity. This may have implications in the management of persistent pain after TKA. Cite this article: Bone Joint J 2021;103-B(6 Supple A):94-101.
Collapse
Affiliation(s)
- Marie E Roy
- Missouri Bone & Joint Research Foundation, St Louis, Missouri, USA
| | - Leo A Whiteside
- Missouri Bone & Joint Research Foundation, St Louis, Missouri, USA
| | - Kevin K Ly
- Missouri Bone & Joint Research Foundation, St Louis, Missouri, USA
| | | |
Collapse
|
8
|
De Smet A, Verrewaere D, Sys G. Enhancing rotational placement of reconstruction prostheses of the distal femur after sarcoma resection. Med Eng Phys 2020; 81:47-57. [PMID: 32507678 DOI: 10.1016/j.medengphy.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/15/2020] [Accepted: 05/05/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Currently there are no accepted international guidelines for the correct placement of reconstruction prostheses in the axial plane of the femur after en bloc resection. The most accepted method is based on the linea aspera as an intraoperative landmark, indicating posterior. This study was conducted to address the reliability of the linea aspera as a landmark for rotational alignment. MATERIAL AND METHODS 50 CT angiographies of the right limb were used for this purpose. These 2D images were reconstructed into 3D models using proprietary software (materialize NV, Leuven, Belgium). The posterior condylar line was used as a reference axis. The orientation of the linea aspera was described as the angle between the perpendicular line to the PCL, through the center of the diaphysis, and the lateral (α) and medial labium (β). RESULTS The linear mixed model shows that the α- and β-angles are significantly associated with the distance from the joint line (p<0.001) and vary significantly between subjects (p<0.001). The α-angle has the lowest variance and approximates more closely true posterior, while the median β-angle never overlaps true posterior. DISCUSSION When a surgeon would blindly rely on the linea aspera as a posterior landmark roughly 78% of the femoral implants would exceed the accepted ±3° deviation around the surgical transepicondylar axis (sTEA) as defined in total knee replacement. The linea aspera is not a reliable landmark for axial rotation of femoral implants. The position is highly dependent on the osteotomy height and in addition differs between individual patients. Preoperative assessment of the linea aspera is advocated in order to reduce the risk of malrotation. As the height of the osteotomy cannot always be determined correctly preoperatively, a table was designed as a guideline for how much a deviation from the planned resection height will affect the rotation of the implant.
Collapse
Affiliation(s)
- Arne De Smet
- Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Belgium.
| | - Dries Verrewaere
- Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, Belgium; Faculty of Medicine and Health Sciences, Ghent University, Belgium.
| | - Gwen Sys
- Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, Belgium; Faculty of Medicine and Health Sciences, Ghent University, Belgium.
| |
Collapse
|
9
|
Are Serum Metal Ion Levels a Concern at Mid-term Followup of Revision Knee Arthroplasty With a Metal-on-metal Hinge Design? Clin Orthop Relat Res 2019; 477:2007-2014. [PMID: 30811355 PMCID: PMC7000071 DOI: 10.1097/corr.0000000000000638] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Elevated serum levels of chromium and cobalt ions in metal-on-metal (MoM) bearing surfaces is a well-known phenomenon in THA. However, few studies have addressed this issue in complex primary and revision knee arthroplasty using a MoM hinged mechanism, and no study, to our knowledge, has investigated knees with MoM hinges in patients without megaprostheses (tumor prostheses). QUESTIONS/PURPOSES We analyzed a series of patients who received MoM hinged revision knee prostheses and asked: (1) What are the serum metal ion levels at short-term followup? (2) Is there any correlation between metal ion levels and the Knee Society Score (KSS) at this followup? METHODS Between 2013 and 2017, we performed 198 revision knee arthroplasties, of which 32 (17.7%) were performed with a latest-generation MoM hinge knee design. In addition, three complex primary TKAs utilizing the same design were included in this study. The device features a metal-on-polyethylene bearing with a MoM hinge. During that period, our general indications for using a hinge were single-stage and two-stage revision surgeries, revisions with large bone defects, and primary TKA with > 20° mechanical malalignment or collateral ligament insufficiency. Of the 35 patients who received this device, 23 patients (65% of the overall group who received this implant; 11 males, 12 females) were available for followup at a median of 28 months (range, 13-61 months), and the remaining 12 (35%) patients were lost to followup. Our rationale for reporting before the more typical 2-year minimum was the finding of elevated serum ion levels with unclear clinical significance. Median age at the time of surgery was 68 years (range, 52-84 years). None of the patients included in the study had other implants with MoM bearings. Serum ion levels of chromium (III) and cobalt were assessed using mass spectrometry. Ion levels > 5 ppb were considered elevated. Clinical outcome was assessed using the original KSS. RESULTS Median chromium serum level was 6.3 ppb (range, 0.6-31.9 ppb) and median cobalt serum level was 10.5 (range, 1.0-47.5 ppb). Of the 23 patients, 16 had elevated serum ion levels. There was a moderate correlation between KSS and both chromium (p = 0.029, r = 0.445) and cobalt (p = 0.012, r = 0.502) levels. CONCLUSIONS Elevated metal ion levels and radiolucent lines are common after surgery with this MoM hinge design at short-term followup, and we believe this finding is of great concern. Although no patient has yet been revised, these patients will be closely monitored. We recommend that serum ion analysis become a routine part of followup after any hinge TKA in an attempt to better understand the potential consequences of this phenomenon. LEVEL OF EVIDENCE Level IV, therapeutic study.
Collapse
|
10
|
Reiner T, Bader N, Panzram B, Bülhoff M, Omlor G, Kretzer JP, Raiss P, Zeifang F. In vivo blood metal ion levels in patients after total shoulder arthroplasty. J Shoulder Elbow Surg 2019; 28:539-546. [PMID: 30518478 DOI: 10.1016/j.jse.2018.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/17/2018] [Accepted: 08/19/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Products from metal wear have been identified as a potential cause of adverse local tissue reactions and implant failure in total hip arthroplasty. However, the role of metal ion exposure in patients after total shoulder replacement is unclear. The objective of the present study was to determine in vivo blood metal ion levels of cobalt, chromium, and titanium in patients after anatomic total shoulder arthroplasty (TSA) or reverse TSA. METHODS A consecutive series of patients after anatomic TSA or reverse TSA was evaluated retrospectively. After exclusion of patients with additional metal implants, 40 patients with unilateral anatomic TSA (n = 20) or reverse TSA (n = 20) were available for whole-blood metal ion analysis at a mean follow-up of 28 ± 9.6 months. Twenty-three healthy individuals without metal implants served as a control group. RESULTS Mean cobalt ion concentrations were 0.18 µg/L (range, 0.1-0.66 µg/L), 0.15 µg/L (range, 0.03-0.48 µg/L), and 0.11 µg/L (range, 0.03-0.19 µg/L), mean chromium ion levels were 0.48 µg/L (range, 0.17-2.41 µg/L), 0.31 µg/L (range, 0.09-1.26 µg/L), and 0.14 µg/L (range, 0.04-0.99 µg/L), and mean titanium ion concentrations were 1.31 µg/L (range, 0.75-4.52 µg/L), 0.84 µg/L (range, 0.1-1.64 µg/L), and 0.62 µg/L (range, 0.32-2.14 µg/L) in the reverse TSA group, the anatomic TSA group, and the control group, respectively. CONCLUSIONS TSA resulted in elevated metal ion levels compared with healthy controls, although overall metal ion concentrations measured in this study were relatively low. The role of local metal ion exposure in patients with total shoulder replacements should be further investigated.
Collapse
Affiliation(s)
- Tobias Reiner
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.
| | - Nina Bader
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Panzram
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Bülhoff
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Georg Omlor
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan P Kretzer
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Patric Raiss
- OCM (Orthopädische Chirurgie München) Clinic for Orthopedic Surgery, Munich, Germany
| | - Felix Zeifang
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
11
|
Postler A, Beyer F, Lützner C, Tille E, Lützner J. Similar outcome during short-term follow-up after coated and uncoated total knee arthroplasty: a randomized controlled study. Knee Surg Sports Traumatol Arthrosc 2018; 26:3459-3467. [PMID: 29616285 DOI: 10.1007/s00167-018-4928-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/28/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE Patients with known hypersensitivity to metals often require hypoallergenic TKA implants. Coating of a standard implant is a common solution, and although in vitro tests have demonstrated reduction of polyethylene wear for these coatings, it is still unknown whether these implants have any clinical benefit. This study was initiated to investigate metal ion concentrations, knee function and patient-reported outcome (PRO) after coated and uncoated TKA. METHODS One hundred and twenty-two (122) patients were randomized to receive a coated or a standard TKA and, after exclusions, 59 patients were included in each group. Knee function and PRO were assessed with validated scores up to 3 years after surgery. Metal ion concentrations in blood samples were determined for chromium, cobalt, molybdenum and nickel, preoperatively and 1 year after surgery. RESULTS Chromium concentrations in patient plasma increased from a median of 0.25 to 1.30 µg/l in the standard TKA group, and from 0.25 to 0.75 µg/l in the coated TKA group (p = 0.012). Thirteen patients (3 coated, 10 standard TKA) had chromium concentrations above 2 µg/l. The concentrations of cobalt, molybdenum and nickel did not change. Patient-reported outcome measures (PROM) demonstrated a substantial improvement after TKA, without any differences between the groups. CONCLUSION The increase in chromium concentration in the standard group needs further investigation. If surgeons use coated implants, they can be confident that these implants perform as well as standard implants. LEVEL OF EVIDENCE I.
Collapse
Affiliation(s)
- Anne Postler
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Franziska Beyer
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Cornelia Lützner
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Eric Tille
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Jörg Lützner
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| |
Collapse
|
12
|
Lons A, Putman S, Pasquier G, Migaud H, Drumez E, Girard J. Metallic ion release after knee prosthesis implantation: a prospective study. INTERNATIONAL ORTHOPAEDICS 2017; 41:2503-2508. [PMID: 28616704 DOI: 10.1007/s00264-017-3528-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 05/25/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Metal-on-metal (MoM) hip replacement bearings produce metallic ions that can cause health complications. Metallic release also occurs with other materials, but data on metallic ion levels after knee arthroplasty are sparse. We postulate that knee replacement generates elevating metallic ions (chromium (Cr), cobalt (Co) and titanium (Ti)) during the first year after implantation. PATIENTS AND METHODS This ongoing prospective study included all patients who underwent the same type of knee arthroplasty between May and December 2013. Cr, Co and Ti levels were measured in whole blood at pre-operation and one-year follow-up (6 and 12 months). Clinical and radiographic data (range of motion, Oxford, International Knee Society (IKS) and satisfaction scores) were recorded. RESULTS In 90 patients, preoperative Cr, Co and Ti metallic ion levels were respectively 0.45 μg/l, 0.22 μg/l, 2.94 μg/l and increased to 1.27 μg/l, 1.41 μg/l, 4.08 μg/l (p < 0.0001) at last one-year follow-up. Mean Oxford and IKS scores rose, respectively, from 45.9 (30-58) and 24.9 (12-52) to 88.3 (0-168) and 160.8 (93-200) (p < 0.001). CONCLUSION After the implantation of knee arthroplasty, we found significant blood elevation of Cr, Co and Ti levels one year after implantation exceeding the normal values. This metallic ion release could lead to numerous effects: allergy, hypersensitivity, etc.
Collapse
Affiliation(s)
- Adrien Lons
- Université de Lille Nord de France, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037, Lille, Cedex, France
| | - Sophie Putman
- Université de Lille Nord de France, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037, Lille, Cedex, France
| | - Gilles Pasquier
- Université de Lille Nord de France, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037, Lille, Cedex, France
| | - Henri Migaud
- Université de Lille Nord de France, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037, Lille, Cedex, France
| | - Elodie Drumez
- Unité de Biostatistiques, Université Lille, Centre Hospitalier Universitaire Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000, Lille, France
| | - Julien Girard
- Université de Lille Nord de France, F-59000, Lille, France.
- Service d'Orthopédie, Hôpital Salengro, Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037, Lille, Cedex, France.
| |
Collapse
|
13
|
Kim EC, Kim MK, Leesungbok R, Lee SW, Ahn SJ. Co-Cr dental alloys induces cytotoxicity and inflammatory responses via activation of Nrf2/antioxidant signaling pathways in human gingival fibroblasts and osteoblasts. Dent Mater 2016; 32:1394-1405. [PMID: 27671470 DOI: 10.1016/j.dental.2016.09.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 08/08/2016] [Accepted: 09/03/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Although cobalt-chromium (Co-Cr) dental alloys are routinely used in prosthodontics, the biocompatibility of Co-Cr alloys is controversial. The aims of the present study were to investigate the effects of Co-Cr alloys on human gingival fibroblasts (HGF) and osteoblasts in an in vitro model as well as their potential molecular mechanisms, focusing on NF-E2-related factor 2 (Nrf2) pathways. METHODS Cells were directly seeded on prepared Co-Cr alloy discs (15.0mm diameter, 1.0mm thickness) or indirectly treated with Co-Cr alloy located at the bottom of an insert well and incubated for 3 days. Cytotoxicity and reactive oxygen species (ROS) production was evaluated by MTS assay and flow cytometry, respectively. Protein and mRNA levels were determined by Western blotting and RT-PCR analysis, respectively. RESULTS Cell viability and flow cytometric assay demonstrated that the Co-Cr alloy was cytotoxic to HGFs and osteoblasts, and significantly increased ROS production. In addition, the Co-Cr alloys upregulated pro-inflamamtory cytokines (TNF-α, IL-1β, IL-6, and IL-8) and increased levels of various inflammatory mediators (iNOS derived nitrite oxide, and COX-2-derived PGE2) in both cells. A mechanistic study showed that Co-Cr alloys activates the NRF2 pathway and up-regulate antioxidant enzymes including heme oxygenase-1 (HO-1). Co-Cr alloys activated JAK2/STAT3, p38/ERK/JNK MAPKs and NF-κB signaling pathways. Furthermore, antioxidants (resveratrol and NAC) and HO-1 inhibitor (SnPP) significantly inhibited the production of ROS and inflammatory mediators, as well as the activation of NF-κB signaling in Co-Cr alloy stimulated HGFs and osteoblasts. SIGNIFICANCE This study is the first to show that Co-Cr alloys exert cytotoxic and inflammatory effects via activation of Nrf2/ARE signaling and up-regulation of downstream HO-1, which could represent candidate targets for the regulation of inflammatory responses to Co-Cr alloys.
Collapse
Affiliation(s)
- Eun-Cheol Kim
- Department of Maxillofacial Tissue Regeneration, School of Dentistry and Institute of Oral Biology, Kyung Hee University, Seoul, Republic of Korea
| | - Myo-Kyoung Kim
- Department of Maxillofacial Tissue Regeneration, School of Dentistry and Institute of Oral Biology, Kyung Hee University, Seoul, Republic of Korea
| | - Richard Leesungbok
- Department of Biomaterials & Prosthodontics, Kyung Hee University Hospital at Gangdong, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea
| | - Suk-Won Lee
- Department of Biomaterials & Prosthodontics, Kyung Hee University Hospital at Gangdong, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea
| | - Su-Jin Ahn
- Department of Biomaterials & Prosthodontics, Kyung Hee University Hospital at Gangdong, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea.
| |
Collapse
|
14
|
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]
|
15
|
Posada OM, Tate RJ, Grant MH. Effects of CoCr metal wear debris generated from metal-on-metal hip implants and Co ions on human monocyte-like U937 cells. Toxicol In Vitro 2014; 29:271-80. [PMID: 25433333 DOI: 10.1016/j.tiv.2014.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 11/07/2014] [Accepted: 11/18/2014] [Indexed: 12/12/2022]
Abstract
Hip resurfacing with cobalt-chromium (CoCr) alloy was developed as a surgical alternative to total hip replacement. However, the biological effects of nanoparticles generated by wear at the metal-on-metal articulating surfaces has limited the success of such implants. The aim of this study was to investigate the effects of the combined exposure to CoCr nanoparticles and cobalt ions released from a resurfacing implant on monocytes (U937 cells) and whether these resulted in morphology changes, proliferation alterations, toxicity and cytokine release. The interaction between prior exposure to Co ions and the cellular response to nanoparticulate debris was determined to simulate the situation in patients with metal-on-metal implants receiving a second implant. Effects on U937 cells were mainly seen after 120h of treatment. Prior exposure to Co ions increased the toxic effects induced by the debris, and by Co ions themselves, suggesting the potential for interaction in vivo. Increased TNF-α secretion by resting cells exposed to nanoparticles could contribute to osteolysis processes in vivo, while increased IFN-γ production by activated cells could represent cellular protection against tissue damage. Data suggest that interactions between Co ions and CoCr nanoparticles would occur in vivo, and could threaten the survival of a CoCr metal implant.
Collapse
Affiliation(s)
- Olga M Posada
- Biomedical Engineering Department, University of Strathclyde, Wolfson Centre, Glasgow G4 0NW, UK.
| | - Rothwelle J Tate
- Strathclyde Institute for Pharmacy & Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK.
| | - M Helen Grant
- Biomedical Engineering Department, University of Strathclyde, Wolfson Centre, Glasgow G4 0NW, UK.
| |
Collapse
|
16
|
CoCr wear particles generated from CoCr alloy metal-on-metal hip replacements, and cobalt ions stimulate apoptosis and expression of general toxicology-related genes in monocyte-like U937 cells. Toxicol Appl Pharmacol 2014; 281:125-35. [DOI: 10.1016/j.taap.2014.09.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/27/2014] [Accepted: 09/22/2014] [Indexed: 12/28/2022]
|
17
|
Serum metal ion concentrations in paediatric patients following total knee arthroplasty using megaprostheses. BIOMED RESEARCH INTERNATIONAL 2014; 2014:817257. [PMID: 25276819 PMCID: PMC4172978 DOI: 10.1155/2014/817257] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/17/2014] [Accepted: 08/11/2014] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to determine the concentrations of cobalt, chromium, and molybdenum in the serum of paediatric tumour patients after fixed hinge total knee arthroplasty. Further, these metal ion levels were compared with serum metal ion levels of patients with other orthopaedic devices such as hip and knee prostheses with metal-on-metal or metal-on-polyethylene articulation to find differences between anatomical locations, abrasion characteristics, and bearing surfaces. After an average follow-up of 108 months (range: 67 to 163) of 11 paediatric patients with fixed hinge total knee arthroplasty, the mean concentrations for Co and Cr were significantly increased while Mo was within the limits compared to the upper values from the reference laboratory. Furthermore, these serum concentrations were significantly higher compared to patients with a standard rotating hinge device (P = 0.002 and P < 0.001) and preoperative controls (P < 0.001). On the other hand, the serum levels of patients following MoM THA or rotating hinge arthroplasty using megaprostheses were higher. Therefore, periodic long-term follow-ups are recommended due to the rising concerns about systemic metal ion exposure in the literature. Upon the occurrence of adverse reactions to metal debris the revision of the fixed hinge implant should be considered.
Collapse
|
18
|
Matusiewicz H. Potential release of in vivo trace metals from metallic medical implants in the human body: from ions to nanoparticles--a systematic analytical review. Acta Biomater 2014; 10:2379-403. [PMID: 24565531 DOI: 10.1016/j.actbio.2014.02.027] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/04/2013] [Accepted: 02/13/2014] [Indexed: 02/06/2023]
Abstract
Metal ion release from metallic materials, e.g. metallic alloys and pure metals, implanted into the human body in dental and orthopedic surgery is becoming a major cause for concern. This review briefly provides an overview of both metallic alloys and pure metals used in implant materials in dental and orthopedic surgery. Additionally, a short section is dedicated to important biomaterials and their corrosive behavior in both real solutions and various types of media that model human biological fluids and tissues. The present review gives an overview of analytical methods, techniques and different approaches applied to the measurement of in vivo trace metals released into body fluids and tissues from patients carrying metal-on-metal prostheses and metal dental implants. Reference levels of ion concentrations in body fluids and tissues that have been determined by a host of studies are compiled, reviewed and presented in this paper. Finally, a collection of published clinical data on in vivo released trace metals from metallic medical implants is included.
Collapse
|
19
|
Primary rotating-hinge total knee arthroplasty: good outcomes at mid-term follow-up. J Arthroplasty 2014; 29:1202-6. [PMID: 24418767 DOI: 10.1016/j.arth.2013.12.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 11/12/2013] [Accepted: 12/07/2013] [Indexed: 02/01/2023] Open
Abstract
We evaluated the clinical and radiologic outcomes of primary knee replacements using a rotating-hinge knee prosthesis in 12 knees with a minimum follow-up of 10 years. Indications for the operation included gross joint destruction, significant axial deformities and contracture with a dysfunctional medial collateral ligament in all cases. The patients' WOMAC and Knee Society scores improved, and the use of mobility aids decreased. No loosening of implants was observed. Nonprogressive radiolucent lines were identified around three tibial components. Three patients required marginal wound excision with resuturing and thereafter healed uneventfully. With significant improvement in function, pain and range of motion, the rotating-hinge knee prosthesis can be used as a salvage device in patients with medial collateral ligament deficiency, contracture, and gross joint destruction.
Collapse
|
20
|
Lützner J, Hartmann A, Dinnebier G, Spornraft-Ragaller P, Hamann C, Kirschner S. Metal hypersensitivity and metal ion levels in patients with coated or uncoated total knee arthroplasty: a randomised controlled study. INTERNATIONAL ORTHOPAEDICS 2013; 37:1925-31. [PMID: 23860793 PMCID: PMC3779567 DOI: 10.1007/s00264-013-2010-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 06/24/2013] [Indexed: 12/23/2022]
Abstract
PURPOSE Metal ion release by orthopaedic implants may cause local and systemic effects and induce hypersensitivity reactions. Coated implants have been developed to prevent or reduce these effects. This study was initiated to investigate the safety of a novel coating for total knee arthroplasty (TKA) implants. METHODS A total of 120 patients undergoing primary TKA with no history of hypersensitivity and no other metal implant were randomised to receive either a coated or uncoated implant. Chromium (Cr), cobalt (Co), molybdenum (Mb) and nickel (Ni) hypersensitivity patch testing and plasma ion concentrations were evaluated pre-operatively and one year post-operatively. RESULTS At the one year follow-up both groups demonstrated significant improvement in knee function and quality of life. One new weakly positive reaction to Co in the TKA group with coated implant and two doubtful skin reactions to Ni (one in each group) were noted. Even with sensitisation to implant materials no skin reactions were observed. Plasma metal ion concentrations did not increase and were not elevated at the one year follow-up in either group. CONCLUSIONS Sensitisation after TKA was rare and had no influence on clinical results. TKA with coated implant and standard TKA demonstrated no plasma metal ion elevation.
Collapse
Affiliation(s)
- Jörg Lützner
- Department of Orthopaedic Surgery, University Hospital Carl Gustav Carus, Medical Faculty of the Technical University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany,
| | | | | | | | | | | |
Collapse
|
21
|
In-vitro-Analyse des Einflusses von Metallionen auf humane Lymphozyten. DER ORTHOPADE 2013; 42:643-50. [DOI: 10.1007/s00132-012-2039-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|