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Abouharb A, Joseph PJS, Pandit H. Existing and Novel Assessment Methods for Metal Sensitivity in Elective Lower-Limb Arthroplasty-A Scoping Review. Arthroplast Today 2024; 28:101462. [PMID: 39170964 PMCID: PMC11338134 DOI: 10.1016/j.artd.2024.101462] [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: 11/20/2023] [Revised: 05/13/2024] [Accepted: 06/09/2024] [Indexed: 08/23/2024] Open
Abstract
Background Metal sensitivity is a possible cause for revision in elective lower-limb arthroplasty. This scoping review aims to identify and evaluate all existing and novel assessment methods for metal sensitivity in elective lower-limb arthroplasty. Methods The Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, and Google Scholar databases were searched for studies published between January 1, 2000, and September 1, 2023. Studies evaluating one or more metal sensitivity assessment method preoperatively, perioperatively, or postoperatively were included. Studies were grouped based on the assessment methods reported and summarized based on the study design, outcome measure, results, and comments on the method's validity. Results A total of 1220 results were screened, with 39 results (15 retrospective cohort studies, 11 prospective cohort studies, 6 case reports, 5 randomized controlled trials, and 2 case control studies) included, identifying 12 assessment methods. The most used one was patch testing, featuring in 17 studies (43.6%). Lymphocyte transformation assay/testing featured in 12 studies (30.8%). Plasma/serum concentration of metal ions featured in 6 studies (15.4%). Patient history and serum cytokine testing featured in 7 (17.9%) and 4 (10.3%) studies each. Generalized serum inflammatory markers featured in 3 studies (7.7%). The remaining 6 methods each featured in one or 2 studies. Evidence of the reliability of most metrics was limited. Conclusions Several assessment methods were identified. However, evidence of any methods reliably predicting and diagnosing the occurrence of metal sensitivity was limited. There is a need for improved metrics of metal hypersensitivity.
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Affiliation(s)
| | | | - Hemant Pandit
- Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, West Yorkshire, UK
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Chen A, Kurmis AP. Understanding immune-mediated cobalt/chromium allergy to orthopaedic implants: a meta-synthetic review. ARTHROPLASTY 2024; 6:1. [PMID: 38303027 PMCID: PMC10835847 DOI: 10.1186/s42836-023-00227-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/12/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND The frequency of primary joint replacement surgery continues to increase worldwide. While largely considered biologically inert entities, an increasing body of evidence continues to validate a not insignificant incidence of allergic reactions to such implants. Little previous work has explored genuinely immune-mediated reactivity in this context. In the absence of a contemporary published summary on the topic, this paper explored the current state of understanding of cobalt/chromium allergy and proposes a patient management algorithm whereby such immune reactions are clinically suggested. METHODS A structured, systematic literature review was performed by following PRISMA search principles to provide an updated review of this area. RESULTS Thirty-six topic-related articles were identified, the majority reflecting lower tiers of scientific evidence with a lack of homogeneous quantitative data to facilitate valid cohort comparisons. Largely, the available literature represented small case series' or expert opinions. CONCLUSIONS Despite increasing clinical awareness and acknowledgement of true allergy to joint replacement components, this review highlighted that the evidence base underpinning the diagnosis and management of such patients is limited. Both patient-reported metal allergy or skin patch testing are grossly unreliable methods and show almost no correlation with true immune reactivity. Recent studies suggested a potential role for patient-specific in vitro cellular activation testing and/or targeted genetic testing when cobalt/chromium allergy is clinically suspected. However, while likely representing the contemporary "best available" approaches both can be costly undertakings, are not yet universally available, and still require broader validation in non-research settings before wider uptake can be championed.
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Affiliation(s)
- Arnold Chen
- School of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Andrew P Kurmis
- Discipline of Medical Specialties, University of Adelaide, Adelaide, SA, 5000, Australia.
- Department of Orthopaedic Surgery, Lyell McEwin Hospital, Elizabeth Vale, SA, 5112, Australia.
- College of Medicine & Public Health, Flinders University, Bedford Park, SA, 5042, Australia.
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3
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Lukas S, Martinot P, Putman S, Lons A, Drumez E, Migaud H, Girard J. Metal ion release after hip resurfacing arthroplasty and knee arthroplasty: a retrospective study of one hundred ninety-five cases. INTERNATIONAL ORTHOPAEDICS 2024; 48:119-126. [PMID: 37650937 DOI: 10.1007/s00264-023-05915-6] [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: 07/04/2023] [Accepted: 07/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Hip arthroplasty with metal-on-metal bearings like hip resurfacing results in the release of metallic ions. In parallel, like every metallic implant, knee arthroplasty implants undergo passive corrosion. We analyzed blood levels of cobalt and chromium ions in patients who have a hip resurfacing arthroplasty and compared them to patients who have undergone knee arthroplasty at a minimum follow-up of one year. The hypothesis was that there is no difference in the ion release between hip resurfacing and knee arthroplasty. METHODS Sixty-three patients who underwent knee arthroplasty were compared to a cohort of 132 patients who underwent hip resurfacing. The blood levels of cobalt and chromium ions were determined preoperatively and at six and 12 months postoperatively and then compared between groups. We analyzed the relationship between ion release and the change in clinical outcome scores (Harris Hip score, Oxford Hip score, Merle D'Aubigné Postel score, Oxford Knee score, International Knee Society score), the BMI, sex, physical activity, implant size and inclination of the acetabular implant (hip resurfacing patients only). Mixed linear models were used to assess the changes in ion blood levels over time. RESULTS The cobalt blood levels were higher in the first 6 months in the resurfacing group (0.87 ug/L vs 0.67 ug/L; p = 0.011), while it was higher in the knee arthroplasty group at 12 months (1.20 ug/L vs 1.41 ug/L; p = 0.0008). There were no significant differences in chromium levels during the follow-up period. CONCLUSION The increase in metal ion release after knee arthroplasty is as high as after hip resurfacing at the one year follow-up. The monitoring of this parameter probably should not be recommended in case of good clinicals outcomes.
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Affiliation(s)
- S Lukas
- Univ. Lille, CHU Lille, ULR 4490-PMOI, F-59000, Lille, France.
- Service d'Orthopédie, Hôpital Salengro, Place de Verdun, CHU Lille, F-59000, Lille, France.
| | - P Martinot
- Département de Chirurgie Orthopédique, Hôpital Saint Philibert, Université Catholique de Lille, Lomme, France
| | - S Putman
- Univ. Lille, CHU Lille, ULR 4490-PMOI, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Place de Verdun, CHU Lille, F-59000, Lille, France
| | - A Lons
- Département de Chirurgie Orthopédique, Hôpital Saint Philibert, Université Catholique de Lille, Lomme, France
| | - E Drumez
- Unité de Biostatistiques, Université Lille, Centre Hospitalier Universitaire Lille, EA 2694-Santé publique: épidémiologie et qualité des soins, F-59000, Lille, France
| | - H Migaud
- Univ. Lille, CHU Lille, ULR 4490-PMOI, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Place de Verdun, CHU Lille, F-59000, Lille, France
| | - J Girard
- Univ. Lille, CHU Lille, ULR 4490-PMOI, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Place de Verdun, CHU Lille, F-59000, Lille, France
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d'Opale, EA 7369-URePSS-Unité de Recherche Pluridisciplinaire Sport Santé Société, F-59000, Lille, France
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4
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Mödinger Y, Anttila ED, Baker GM, Gross DC, Porporati AA. Magnetic Resonance Safety Evaluation of a Novel Alumina Matrix Composite Ceramic Knee and Image Artifact Comparison to a Metal Knee Implant of Analogous Design. Arthroplast Today 2023; 22:101170. [PMID: 37521740 PMCID: PMC10374871 DOI: 10.1016/j.artd.2023.101170] [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: 05/22/2023] [Accepted: 06/08/2023] [Indexed: 08/01/2023] Open
Abstract
Background Image artifacts caused by metal knee implants in 1.5T and 3T magnetic resonance imaging (MRI) systems complicate imaging-based diagnosis of the peri-implant region after total knee arthroplasty. Alternatively, metal-free knee prostheses could effectively minimize MRI safety hazards and offer the potential for higher quality diagnostic images. Methods A novel knee arthroplasty device composed of BIOLOX delta, an alumina matrix composite (AMC) ceramic, was tested in a magnetic resonance (MR) environment. American Society for Testing and Materials test methods were used for evaluating magnetically induced displacement force, magnetically induced torque, radiofrequency-induced heating, and MR image artifact. Results Magnetically induced displacement force and magnetically induced torque results of the AMC ceramic knee indicated that these effects do not pose a known risk in a clinical MR environment, as assessed in a 3T magnetic field. Moreover, minimal radiofrequency-induced heating of the device was observed. In addition, the AMC ceramic knee demonstrated minimal MR image artifacts (7 mm) in comparison to a cobalt-chromium knee (88 mm). The extremely low magnetic susceptibility of AMC (2 ppm) underlines that it is a nonmetallic and nonmagnetic material well suited for the manufacturing of MR Safe orthopaedic implants. Conclusions The AMC ceramic knee is a novel metal-free total knee arthroplasty device that can be regarded as MR Safe, as suggested by the absence of hazards from the exposure of this implant to a MR environment. The AMC ceramic knee presents the advantage of being scanned with superior imaging results in 3T MRI systems compared to alternative metal implants on the market.
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Affiliation(s)
- Yvonne Mödinger
- Medical Products Division, CeramTec GmbH, Plochingen, Germany
| | | | | | | | - Alessandro A. Porporati
- Medical Products Division, CeramTec GmbH, Plochingen, Germany
- Department of Engineering and Architecture, University of Trieste, Trieste, Italy
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5
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Okutan B, Schwarze UY, Berger L, Martinez DC, Herber V, Suljevic O, Plocinski T, Swieszkowski W, Santos SG, Schindl R, Löffler JF, Weinberg AM, Sommer NG. The combined effect of zinc and calcium on the biodegradation of ultrahigh-purity magnesium implants. BIOMATERIALS ADVANCES 2023; 146:213287. [PMID: 36669235 DOI: 10.1016/j.bioadv.2023.213287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
Magnesium (Mg)-based implants are promising candidates for orthopedic interventions, because of their biocompatibility, good mechanical features, and ability to degrade completely in the body, eliminating the need for an additional removal surgery. In the present study, we synthesized and investigated two Mg-based materials, ultrahigh-purity ZX00 (Mg-Zn-Ca; <0.5 wt% Zn and <0.5 wt% Ca, in wt%; Fe-content <1 ppm) and ultrahigh-purity Mg (XHP-Mg, >99.999 wt% Mg; Fe-content <1 ppm), in vitro and in vivo in juvenile healthy rats to clarify the effect of the alloying elements Zn and Ca on mechanical properties, microstructure, cytocompatibility and degradation rate. Potential differences in bone formation and bone in-growth were also assessed and compared with state-of-the-art non-degradable titanium (Ti)-implanted, sham-operated, and control (non-intervention) groups, using micro-computed tomography, histology and scanning electron microscopy. At 6 and 24 weeks after implantation, serum alkaline phosphatase (ALP), calcium (Ca), and Mg level were measured and bone marrow stromal cells (BMSCs) were isolated for real-time PCR analysis. Results show that ZX00 implants have smaller grain size and superior mechanical properties than XHP-Mg, and that both reveal good biocompatibility in cytocompatibilty tests. ZX00 homogenously degraded with an increased gas accumulation 12 and 24 weeks after implantation, whereas XHP-Mg exhibited higher gas accumulation already at 2 weeks. Serum ALP, Ca, and Mg levels were comparable among all groups and both Mg-based implants led to similar relative expression levels of Alp, Runx2, and Bmp-2 genes at weeks 6 and 24. Histologically, Mg-based implants are superior for new bone tissue formation and bone in-growth compared to Ti implants. Furthermore, by tracking the sequence of multicolor fluorochrome labels, we observed higher mineral apposition rate at week 2 in both Mg-based implants compared to the control groups. Our findings suggest that (i) ZX00 and XHP-Mg support bone formation and remodeling, (ii) both Mg-based implants are superior to Ti implants in terms of new bone tissue formation and osseointegration, and (iii) ZX00 is more favorable due to its lower degradation rate and moderate gas accumulation.
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Affiliation(s)
- Begüm Okutan
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - Uwe Y Schwarze
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria; Department of Dentistry and Oral Health, Division of Oral Surgery and Orthodontics, Medical University of Graz, Billrothgasse 4, 8010 Graz, Austria.
| | - Leopold Berger
- Laboratory of Metal Physics and Technology, Department of Materials, ETH Zurich, Vladimir-Prelog-Weg 4, 8093 Zurich, Switzerland.
| | - Diana C Martinez
- Department of Materials Science and Engineering, Warsaw University of Technology, Woloska 141, 02-507 Warsaw, Poland.
| | - Valentin Herber
- Department of Dentistry and Oral Health, Division of Oral Surgery and Orthodontics, Medical University of Graz, Billrothgasse 4, 8010 Graz, Austria; Department of Oral Surgery, University Center for Dental Medicine, University of Basel, Mattenstrasse 40, 4058 Basel, Switzerland.
| | - Omer Suljevic
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - Tomasz Plocinski
- Department of Materials Science and Engineering, Warsaw University of Technology, Woloska 141, 02-507 Warsaw, Poland.
| | - Wojciech Swieszkowski
- Department of Materials Science and Engineering, Warsaw University of Technology, Woloska 141, 02-507 Warsaw, Poland.
| | - Susana G Santos
- i3S - Instituto de Investigação e Inovação em Saúde, and INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen 208, Porto 4200-135, Portugal.
| | - Rainer Schindl
- Gottfried Schatz Research Center, Biophysics, Medical University of Graz, Neue Stiftingtalstrasse 6, 8010 Graz, Austria.
| | - Jörg F Löffler
- Laboratory of Metal Physics and Technology, Department of Materials, ETH Zurich, Vladimir-Prelog-Weg 4, 8093 Zurich, Switzerland.
| | - Annelie M Weinberg
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - Nicole G Sommer
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria.
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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.
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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;
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7
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Chisari E, Magnuson JA, Ong CB, Parvizi J, Krueger CA. Ceramic-on-polyethylene hip arthroplasty reduces the risk of postoperative periprosthetic joint infection. J Orthop Res 2022; 40:2133-2138. [PMID: 34812555 DOI: 10.1002/jor.25230] [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: 09/07/2021] [Revised: 11/02/2021] [Accepted: 11/20/2021] [Indexed: 02/04/2023]
Abstract
Metal-on-polyethylene (MoP) total hip arthroplasty (THA) prostheses are known to release metal debris. Basic science studies suggest that metal implants induce a pro-inflammatory response that ultimately chemoattracts leukocytes including macrophages and neutrophils to the surgical site. This raises concern of higher risk of infection with these prostheses through the "trojan horse" mechanism by which neutrophils and macrophages transport intracellular pathogens from a remote site. This study compared the infection occurrence between MoP and ceramic-on-polyethylene (CoP) implants to determine if a higher infection rate in MoP is present. We reviewed a consecutive series of 6052 CoP and 4550 MoP primary THA patients from 2015 to 2019. The occurrence of periprosthetic joint infection at 2 years was defined according to the 2018 ICM definition. Statistical analysis consisted of descriptive statistics, univariate analysis, and regression modeling. When compared to CoP, MoP patients were older, included more females, had a higher body mass index, and more commonly affected by comorbidities according to Elixhauser's score. Total revisions were higher in the MoP group (3.19% vs. 2.41%) The absolute incidence of PJI was higher in MoP (2.40% vs. 1.64%). When we adjusted for confounding factors, MoP was found independently associated with a higher PJI risk. Despite MoP and CoP both being widely used for primary THA, we found a higher incidence of PJI in MoP patients. The association remained significant when controlled for possible confounders. We hypothesize that leukocyte recruitment to these implants may play a role and should be further investigated.
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Affiliation(s)
- Emanuele Chisari
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Justin A Magnuson
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christian B Ong
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chad A Krueger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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8
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The Electrochemical Behavior of Ti in Human Synovial Fluids. MATERIALS 2022; 15:ma15051726. [PMID: 35268957 PMCID: PMC8910938 DOI: 10.3390/ma15051726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 11/18/2022]
Abstract
In this study, we report results of the interaction of titanium (Ti) with human synovial fluids. A wide palette of electrochemical techniques was used, including open circuit potential, potentiodynamic methods, and electrochemical impedance. After the electrochemical testing, selected surfaces were analyzed using Auger Electron Spectroscopy to provide laterally resolved information on surface chemistry. For comparison purposes, similar tests were conducted in a series of simulated body fluids. This study shows that compared to the tested simulated body fluids, synovial liquids show a large patient variability up to one order of magnitude for some crucial electrochemical parameters such as corrosion current density. The electrochemical behavior of Ti exposed to human synovial fluids seems to be controlled by the interaction with organic molecules rather than with reactive oxygen species.
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9
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Matar HE, Porter PJ, Porter ML. Metal allergy in primary and revision total knee arthroplasty : a scoping review and evidence-based practical approach. Bone Jt Open 2021; 2:785-795. [PMID: 34587776 PMCID: PMC8558451 DOI: 10.1302/2633-1462.210.bjo-2021-0098.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Aims Metal allergy in knee arthroplasty patients is a controversial topic. We aimed to conduct a scoping review to clarify the management of metal allergy in primary and revision total knee arthroplasty (TKA). Methods Studies were identified by searching electronic databases: Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and Embase, from their inception to November 2020, for studies evaluating TKA patients with metal hypersensitivity/allergy. All studies reporting on diagnosing or managing metal hypersensitivity in TKA were included. Data were extracted and summarized based on study design, study population, interventions and outcomes. A practical guide is then formulated based on the available evidence. Results We included 38 heterogeneous studies (two randomized controlled trials, six comparative studies, 19 case series, and 11 case reports). The evidence indicates that metal hypersensitivity is a rare complication with some histopathological features leading to pain and dissatisfaction with no reliable screening tests preoperatively. Hypoallergenic implants are viable alternatives for patients with self-reported/confirmed metal hypersensitivity if declared preoperatively; however, concerns remain over their long-term outcomes with ceramic implants outperforming titanium nitride-coated implants and informed consent is paramount. For patients presenting with painful TKA, metal hypersensitivity is a diagnosis of exclusion where patch skin testing, lymphocyte transformation test, and synovial biopsies are useful adjuncts before revision surgery is undertaken to hypoallergenic implants with shared decision-making and informed consent. Conclusion Using the limited available evidence in the literature, we provide a practical approach to metal hypersensitivity in TKA patients. Future national/registry-based studies are needed to identify the scale of metal hypersensitivity, agreed diagnostic criteria, and management strategies. Cite this article: Bone Jt Open 2021;2(10):785–795.
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Affiliation(s)
- Hosam E Matar
- Wrightington Hospital, Wigan, UK.,Nottingham Elective Orthopaedic Services, Nottingham University Hospital NHS Trust, Nottingham, UK
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10
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Kenny F, Gibbons JP, Keogh P, O'Byrne J. Revision of total knee replacement (TKR) secondary to raised cobalt levels: should this be considered in the painful TKR patient? BMJ Case Rep 2021; 14:14/7/e240674. [PMID: 34266815 DOI: 10.1136/bcr-2020-240674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 63-year-old woman was referred to the specialised knee revision clinic with ongoing knee pain after total knee replacement. She incidentally had cobalt and chromium levels measured. These were seen to be elevated. Comprehensive assessment and investigation did not identify any other source of cobalt or chromium. Aseptic loosening of the knee was diagnosed, and the knee was revised. At the time of surgery, the tissue was seen to be darkened consistent with metallosis. Multiple samples excluded infection on extended cultures. Aspirated fluid showed that periprosthetic fluid had elevated cobalt levels. The knee was successfully revised with good symptomatic outcome and significantly, over the course of several months post-revision, the cobalt and chromium levels returned to normal.
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Affiliation(s)
- Fred Kenny
- School of Medicine, University of Limerick, Castletroy, Limerick, Ireland
| | - John P Gibbons
- Orthopaedic Department, Cappagh National Orthopaedic Hospital, Dublin, Ireland
| | - Peter Keogh
- Orthopaedic Department, Cappagh National Orthopaedic Hospital, Dublin, Ireland
| | - John O'Byrne
- Orthopaedic Department, Cappagh National Orthopaedic Hospital, Dublin, Ireland
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11
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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.
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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
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12
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BLOOD CHROMIUM-COBALT LEVELS IN PATIENTS AFTER TOTAL KNEE ARTHROPLASTY AND THEIR EFFECT ON THE RETINAL NERVE FIBER LAYER AND MACULAR GANGLION CELL COMPLEX. Retina 2021; 40:1200-1206. [PMID: 31021899 DOI: 10.1097/iae.0000000000002535] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To study blood cobalt (Co) and chromium (Cr) levels in patients who have undergone total knee arthroplasty and their effect on the retinal nerve fiber layer and macular ganglion cell complex. METHODS One hundred patients who had undergone total knee arthroplasty and 50 healthy individuals who had no implants were included in the study. The patients were separated into two groups based on how long ago the prosthesis had been implanted (Group 1: 1 to 5 years; Group 2: 5 to 10 years). After a complete ophthalmological examination, retinal nerve fiber layer and macular ganglion cell complex of the patients were evaluated with optical coherence tomography, performed on dilated pupils. To assess the metal ion levels of the patients, venous blood samples were drawn from each patient. RESULTS The mean age of the patients was 64.72 ± 6.26 years in Group 1, 67.80 ± 8.07 years in Group 2, and 63.42 ± 7.90 years in the control group. In the comparison of age and sex, there were no statistically significant differences between the groups and the control group. Co and Cr levels were statistically higher in Group 1 and Group 2 compared with the control group (P < 0.001). Mean retinal nerve fiber layer thicknesses and mean macular ganglion cell complex thicknesses in Group 1 and Group 2 were statistically lower than in the control group. CONCLUSION Levels of Co and Cr are higher in patients who undergone total knee arthroplasty than healthy subjects, and these higher levels were associated with changes in the retinal nerve fiber layer and macular ganglion cell complex.
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Rakow A, Schoon J. Systemic Effects of Metals Released from Arthroplasty Implants – a Brief Summary. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 158:501-507. [DOI: 10.1055/a-1187-1751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AbstractIn recent years, increasing concern has been raised regarding potential systemic toxicity of metals released from arthroplasty implants. A lack of valid metal thresholds for human (organ) toxicity and the prospect of multi-decade survival of modern hip and knee replacements pose special challenges. Indeed, evidence of systemic effects of metals released from such implants is largely missing. Systemic cobalt exposure has repeatedly been associated with cardiotoxic and neurotoxic effects, and also with thyroid dysfunction. The toxic potential of chromium is considered less pronounced. Yet, in arthroplasty there is usually a co-exposure to chromium and cobalt which complicates evaluation of element-specific effects. Toxicity of titanium dioxide nanoparticles has been subject to debate among international regulatory authorities. Their wide use in a variety of products in everyday life, such as toothpaste, cosmetics and food colorants, hampers the assessment of an
arthroplasty-induced systemic titanium exposure. To date there is no clear evidence for systemic complications due to titanium dioxide released from arthroplasty implants. Release of further metals such as tantalum, niobium, nickel, vanadium and zirconium from hip and knee replacement implants has been described occasionally, but systemic effects of respective long-term exposure scenarios are unknown. Generally, the characterization of all released metals regarding their chemical and physical specifications is critical for the evaluation of potential systemic risks. Systematic studies investigating the accumulation of metals relevant in arthroplasty in different organs/organ systems and the biological consequences of such accumulations are urgently needed.
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Affiliation(s)
- Anastasia Rakow
- Center for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
| | - Janosch Schoon
- Klinik und Poliklinik für Orthopädie und Orthopädische Chirurgie, Universitätsmedizin Greifswald, Germany
- Julius Wolff Institute, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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Bormann T, Jäger S, Kretzer JP, Nebel L, Clarius L, Omlor G, Bitsch R, Lehner B. Retrieval Analysis of Modern Knee Tumor Megaendoprosthesis Shows Considerable Volumetric Metal Wear Generated at the Rotating Hinge. MATERIALS 2020; 13:ma13071519. [PMID: 32224971 PMCID: PMC7178100 DOI: 10.3390/ma13071519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 12/20/2022]
Abstract
Frequently occurring damage, as well as elevated blood metal ion levels, are reported in relation to a tumor and revision system for total knee arthroplasty (TKA), which applies a rotating hinge coupling with a metal-on-metal (MoM) articulation. As the patient collective for this specific system is small, there is no data on wear generated from the couplings. In this study, wear volume and influencing parameters were investigated at 44 retrieved TKAs with MoM couplings. A scoring system rating frequently occurring abrasive wear between 0 (no wear) and 3 (distinct wear) was established. The wear score was correlated to time in vivo, bone resection length, patient weight and polyethylene inlay damage. Volumetric wear was estimated applying coordinate measurements. An elevated wear score of two or higher was found in 43% of cases. The mean wear rate accounted to 7.8 mm3/year. The main influencing coefficient for the extent of wear is time in vivo. We found a tendency for higher wear scores with higher inlay degradation scores. Patient weight and bone resection length did not impact coupling wear. Assessment of wear damage by a semi-quantitative scoring system has proven to be a reliable option for non-destructive coupling evaluation. The generated wear volume is high.
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Affiliation(s)
- Therese Bormann
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, 69118 Heidelberg, Germany; (S.J.); (J.P.K.); (L.N.); (L.C.)
- Correspondence:
| | - Sebastian Jäger
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, 69118 Heidelberg, Germany; (S.J.); (J.P.K.); (L.N.); (L.C.)
| | - J. Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, 69118 Heidelberg, Germany; (S.J.); (J.P.K.); (L.N.); (L.C.)
| | - Laura Nebel
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, 69118 Heidelberg, Germany; (S.J.); (J.P.K.); (L.N.); (L.C.)
| | - Lucas Clarius
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, 69118 Heidelberg, Germany; (S.J.); (J.P.K.); (L.N.); (L.C.)
| | - Georg Omlor
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, 69118 Heidelberg, Germany; (G.O.); (B.L.)
| | - Rudi Bitsch
- ATOS Clinic Heidelberg, 69115 Heidelberg, Germany;
| | - Burkhard Lehner
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, 69118 Heidelberg, Germany; (G.O.); (B.L.)
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Reiner T, Sorbi R, Müller M, Nees T, Kretzer JP, Rickert M, Moradi B. Blood Metal Ion Release After Primary Total Knee Arthroplasty: A Prospective Study. Orthop Surg 2020; 12:396-403. [PMID: 32023362 PMCID: PMC7189061 DOI: 10.1111/os.12591] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/30/2019] [Accepted: 11/18/2019] [Indexed: 12/14/2022] Open
Abstract
Objectives To investigate the course of in vivo blood metal ion levels in patients undergoing primary total knee arthroplasty (TKA) and to investigate potential risk factors associated with metal ion release in these patients. Methods Twenty‐five patients with indication for TKA were included in this prospective study. Whole blood metal ion analysis was performed pre‐operatively and at 1 week, 6 weeks, 3 months, 6 months, and 12 months postoperatively. Clinical scores were obtained using the American Knee Society Score (AKSS) and the Oxford Knee Score (OKS) at each follow‐up and patientsʼ activity levels were assessed by measuring the mean annual walking cycles at 12 months follow‐up. Anteroposterior and lateral radiographs of the operated knee were evaluated postoperatively and at 12‐month follow‐up with regard to implant position and radiological signs of implant loosening. Correlation analysis using multivariate linear regression was performed to investigate the influence of different variables (age, gender, functional scores, number of walking cycles, and body mass index [BMI]) on blood cobalt ion concentrations. Results Mean metal ion levels of cobalt, chromium, molybdenum, and titanium were 0.28 μg/L (SD, 0.14), 0.43 μg/L (SD, 0.49), 0.62 μg/L (SD, 0.45), and 1.96 μg/L (SD, 0.98), respectively at 12‐month follow‐up. Mean cobalt ion levels significantly increased 1‐year after surgery compared to preoperative measurements. There was no statistically significant increase of mean metal ion levels of chromium, titanium, and molybdenum at 1‐year follow‐up. Overall, metal ion levels were low and no patient demonstrated cobalt ion levels above 1 μg/L. Postoperative radiographs demonstrated well‐aligned TKAs in all patients and no signs of osteolysis or implant loosening were detected at 1‐year follow‐up. Both the AKSS and OKS significantly improved during the course of the study up to the final follow‐up. Multivariate regression analysis did not show a statistically significant correlation between the tested variables and blood cobalt ion concentrations. Conclusion A statistically significant increase of mean cobalt ion concentration at 1‐year follow‐up was found in this cohort of patients with well‐functioning TKA, although overall blood metal ion levels were relatively low. Despite low systemic metal ion concentrations seen in this cohort, the local effects of increased metal ion concentrations in the periprosthetic environment on the long‐term outcome of TKA should be further investigated.
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Affiliation(s)
- Tobias Reiner
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Reza Sorbi
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Maike Müller
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Timo Nees
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Rickert
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Giessen and Marburg (UKGM), Giessen, Germany
| | - Babak Moradi
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
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Development, validation and application of an inductively coupled plasma – mass spectrometry method to determine cobalt in metal-on-metal prosthesis patients using volumetric absorptive microsampling. Talanta 2020; 208:120055. [DOI: 10.1016/j.talanta.2019.06.055] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/09/2019] [Accepted: 06/13/2019] [Indexed: 11/20/2022]
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Reiner T, Klotz MC, Seelmann K, Hertzsch F, Innmann MM, Streit MR, Nees TA, Moradi B, Merle C, Kretzer JP, Gotterbarm T. Long-Term Results of a Second-Generation, Small-Diameter, Metal-On-Metal Bearing in Primary Total Hip Arthroplasty at 14-year Follow-Up. MATERIALS 2020; 13:ma13030557. [PMID: 31991553 PMCID: PMC7040657 DOI: 10.3390/ma13030557] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/13/2020] [Accepted: 01/20/2020] [Indexed: 12/12/2022]
Abstract
(1) Background: The objective of the present study was to review the clinical and radiological results of a small-head, MoM bearing in primary THA and to determine blood metal ion levels at long-term follow-up. (2) Methods: We retrospectively evaluated the clinical and radiological results of 284 small-diameter, MoM 28-mm Metasul THA at a mean follow-up of 14.5 years, and measured blood metal ion concentrations in 174 of these patients. (3) Results: After 14 years, survival free for revision due to any reason was 94%. Proximal femoral osteolysis was seen in 23% of hips, and MRI demonstrated ARMD in 27 of the 66 investigated hips (41%). Mean cobalt, chromium, and titanium ion concentrations were 0.82 µg/L (range 0.22-4.45), 1.51 µg/L (0.04-22.69), and 2.68 µg/L (0.26-19.56) in patients with unilateral THA, and 2.59 µg/L (0.43-24.75), 2.50 µg/L (0.26-16.75), and 3.76 µg/L (0.67-19.77), respectively in patients with bilateral THA. Twenty-nine percent of patients showed cobalt or chromium ion levels > 2 µg/L. (4) Conclusions: Despite good clinical long-term results, increased blood metal ion levels (cobalt or chromium > 2 µg/L) were found in approximately one-third of asymptomatic patients, and proximal femoral osteolysis and ARMD were frequently seen in this cohort. Blood metal ion analysis appears helpful in the long-term follow-up of these patients in order to identify individuals at risk. In accordance with contemporary consensus statements, symptomatic patients with elevated metal ion levels and/or progressive osteolysis should be considered for additional CT or MARS MRI to determine the extent of soft tissue affection prior to revision surgery. Further studies are necessary to investigate the clinical relevance of ARMD in asymptomatic patients with small-head, MoM THA.
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Affiliation(s)
- Tobias Reiner
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
- Correspondence: ; Tel.: +49-6221-5634803; Fax: +49-6221-5626360
| | - Matthias C. Klotz
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Kirsten Seelmann
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Fabian Hertzsch
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Moritz M. Innmann
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Marcus R. Streit
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Timo A. Nees
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Babak Moradi
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Christian Merle
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Jan Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, 69118 Heidelberg, Germany;
| | - Tobias Gotterbarm
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
- Department of Orthopedics, Kepler University Hospital, Krankenhausstr. 7a, 4020 Linz, Austria
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Is There Material Loss at the Conical Junctions of Modular Components for Total Knee Arthroplasty? J Arthroplasty 2019; 34:2479-2486. [PMID: 31227303 DOI: 10.1016/j.arth.2019.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 02/01/2023] Open
Abstract
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.
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The patient results and satisfaction of knee arthroplasty in a validated grading system. INTERNATIONAL ORTHOPAEDICS 2019; 43:2747-2755. [PMID: 31515593 DOI: 10.1007/s00264-019-04412-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/03/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The validated Knee Osteoarthritis Grading System (KOGS) was implemented and clinical results were compared with patient satisfaction data and implant survivorship in a multi-centre study with surgeons familiar with unicompartmental knee arthroplasty (UKA), patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA). This is also the first study to evaluate the prevalence of UKA and TKA in consecutive osteoarthritis (OA) knee arthroplasties assessed by this system.. METHOD A consecutive cohort of knees was gathered at three different institutions as categorized by KOGS and surgically treated with the recommended implant unless clinical reasons or patient preference precluded such an option. One thousand one hundred seventy-seven consecutive knees were evaluated including 311 TKA (26%), 695 medial UKA (59%), 154 lateral UKA (13%) and 17 PFA (2%) and the results of the categories evaluated with the Oxford Knee Score (OKS) and the complications reflected in the different categories. RESULTS The failure rate of the UKA (3.5%) or TKA (1.6%) is not higher than accepted results in the literature and the difference in complications is negligible between the UKA (72%) and TKA (26%) cohorts. Revision of a UKA to a TKA as an endpoint was 0.58% with ipsilateral progression at 0.8% over a period of five to 84 months (mean follow-up of 36 months) despite the 'excessive' proportion of UKA in this cohort. The Oxford Score improvement is significant in TKA and UKA and contributes to the acceptable outcomes (The OKS for TKA improved from 20 pre-operatively to 36 post-operatively and the UKA improved from 22 pre-operatively to 39 post-operatively). CONCLUSION KOGS achieves acceptable early survival and functional results when implemented and is a suitable tool for identifying the preferred implant as was validated.
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Prevalence of metal hypersensitivity in total knee replacement. J Orthop 2019; 16:468-472. [PMID: 31680733 DOI: 10.1016/j.jor.2019.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/25/2019] [Indexed: 01/04/2023] Open
Abstract
Background Cutaneous and local reactions to metals used in orthopaedic implants have been well documented. The prevalence of metal sensitivity in general population is 10%-15%. Nickel, Cobalt and Chromium are the most common allergen. The association between cutaneous reactions and implants has been less understood. Hence, this study was taken up with the aim to assess the prevalence of metal hypersensitivity in Total Knee Replacement (TKR) patients and find the most prevalent allergen. Materials & methods Longitudinal study conducted during January-December 2017. We enrolled 233 subjects who were at least three months postoperative. Radiological assessment was done. CREDISOL® kit was used for patch test. Results were recorded using ICDRG grading at 48 hours and five days. Results Mean age was 59.59 years; 12.01% were symptomatic. Pain followed by loss of function were the most common symptoms. However, loss of function and patient dissatisfaction towards procedure were significantly associated with metal hypersensitivity (χ2 value > 3.84; p value < 0.05). In 66% subjects, pre-operative diagnosis was severe osteoarthritis, followed by rheumatoid arthritis (23%). None of the subjects had evidence of loosening on X-ray. Prevalence of Metal Hypersensitivity was found to be 15.87% (patch test positive). Chromium (11.58%) was found to be most common allergen followed by Nickel (8.58%) and then Cobalt (6.43%). Conclusions Significant prevalence of metal hypersensitivity was found. Therefore, we recommend pre-operative patch test for detecting allergic reactions to implants. Alternatives like Titanium or Zirconium can be used to avoid complications.
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Fröschen FS, Gravius N, Lau JF, Randau TM, Kaup E, Friedrich MJ, Gravius S. A case series of cementless revision total knee arthroplasty in patients with benzoyl peroxide allergy. INTERNATIONAL ORTHOPAEDICS 2018; 43:2323-2331. [PMID: 30539218 DOI: 10.1007/s00264-018-4273-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/03/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE The contact allergens nickel, cobalt, and chromium are often discussed as possible triggers of allergic reactions to orthopedic implants. Additionally, acrylates and polymerization additives in bone cement (e.g., benzoyl peroxide (BPO)) have been implicated as triggers of eczema, wound healing disorders, and aseptic implant loosening. We report about six patients with aseptic loosening after total knee arthroplasty (TKA), who underwent revision surgery after testing positive for BPO hypersensitivity. METHODS After clarification of possible other causes of implant failure, epicutaneous testing had been performed and the implants were replaced in a two-stage procedure with cementless, diaphyseal anchoring, hypoallergenic (TiNb-coated) revision endoprostheses. RESULTS Epicutaneous testing revealed a BPO allergy in all six patients and an additional nickel allergy in three of the six patients. There was no histopathological or microbiological evidence for a periprosthetic infection. The clinical follow-up showed a low level of pain with good function, a stable knee joint, and proper implant position. The Knee Society Score (KSS) with its subscales Knee Score and Functional Score improved post-operatively from 43 to 70 points and from 47.5 to 68.3 points, respectively. Two implant-specific complications occurred: femoral stress shielding two years post-operatively with no further need for action and aseptic loosening of the tibial stem with the need of revision three years post-operatively. CONCLUSIONS The regression of complaints after replacement with cementless and nickel-free revision implants suggests allergic implant intolerance. Implantation of a cementless, hypoallergenic endoprosthesis might, therefore, be a surgical treatment strategy in patients with evidence of allergies.
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Affiliation(s)
- Frank S Fröschen
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany.
| | - Nadine Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Jan-Frederic Lau
- Department of Pathology, University Hospital Bonn, Bonn, Germany
| | - Thomas Martin Randau
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Eva Kaup
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Max J Friedrich
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Sascha Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
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Marie-Hardy L, O'Laughlin P, Bonnin M, Ait Si Selmi T. Are dual mobility cups associated with increased metal ions in the blood? Clinical study of nickel and chromium levels with 29 months' follow-up. Orthop Traumatol Surg Res 2018; 104:1179-1182. [PMID: 30297115 DOI: 10.1016/j.otsr.2018.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 07/28/2018] [Accepted: 08/25/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Dual mobility cups have become the implant of choice for older patients with a high risk of dislocation. However, to our knowledge, no study has explored the possibility of metal ion production with these implants that incorporate a polyethylene-on-metal bearing. This led us to conduct a prospective study to determine whether use of a dual mobility cup is accompanied by increased levels of nickel and chromium in the blood. HYPOTHESIS Use of a dual mobility cup is accompanied by an increase of nickel and chromium levels in the blood. METHODS Between 2012 and 2015, 16 consecutive patients were enrolled in the study. They underwent primary hip arthroplasty with a ceramic Biolox™ head (CeramTec, Plochingen, Germany), Corail™ titanium alloy stem (DePuy Synthes, Saint Priest, France) and a Novae™ dual mobility cup (SERF, Décines-Charpieu, France) consisting of 19% chromium (Cr) and 13-15% nickel (Ni). Patients who had other potential sources of nickel or chromium in their body (joint implants, dental implants, etc.) were excluded. The blood levels (μg/L) of nickel and chromium were measured preoperatively and at 2 years' follow-up by an independent laboratory (Biomnis) using inductively coupled plasma mass spectrometry. The upper limits set by the laboratory were<0.87μg/L for chromium and<1.0μg/L for nickel. AP and lateral X-rays of the pelvis were taken preoperatively and at each postoperative follow-up visit to look for signs of loosening. The Postel-Merle-d'Aubigné (PMA) score was determined preoperatively and at each postoperative follow-up visit. Surgical revision procedures for any cause were also documented. RESULTS The mean follow-up was 29 months [13-39]. Preoperatively, blood nickel ion levels were measured in 7 patients; they were below 1μg/L in 6 patients (86%) and at 1.5μg/L in 1 patient (14%). The mean preoperative chromium ion levels (n=7) was 0.2μg/L [0-0.8μg/L]. Postoperatively, all 16 enrolled patients had their blood ion levels checked at a mean follow-up of 29 months. The nickel ion levels averaged 1.69±1.49 [0.2-5.6] (with 4/16 having>2μg/L and 12/16>1μg/L) and the chromium ion levels averaged 0.5±0.11 [0.4-0.7] (with no patients>0.7μg/L). There were no signs of loosening or osteolysis on the follow-up radiographs. The mean PMA score at 2 years was 17.8 [17,18]. CONCLUSION We found that dual mobility cups generate increased nickel but not chromium ions in the blood. The levels measured are comparable to those for other orthopedic implants such as spine implants. The clinical consequences of these increased levels are not known. Nevertheless, there were no clinical or radiological signs of loosening, although the follow-up was only 2 years. LEVEL OF EVIDENCE IV, Cohort study.
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Affiliation(s)
- Laura Marie-Hardy
- Centre orthopédique Paul-Santy-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France.
| | - Padhraig O'Laughlin
- Centre orthopédique Paul-Santy-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France
| | - Michel Bonnin
- Centre orthopédique Paul-Santy-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France
| | - Tarik Ait Si Selmi
- Centre orthopédique Paul-Santy-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France
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Kumar V, Mishra RK, Kaur G, Dutta D. Cobalt and nickel impair DNA metabolism by the oxidative stress independent pathway. Metallomics 2018; 9:1596-1609. [PMID: 29058747 DOI: 10.1039/c7mt00231a] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The oxidative stress that evolves under cobalt and nickel exposure is thought to exert toxicity, though the exact routes of such metal poisoning remain ambiguous. We revisited the metal toxicity in Escherichia coli to show that cobalt and nickel exposure at levels as low as 0.5 and 1 mM, respectively, visibly inhibits growth. We also observed that acidic conditions aggravated, while alkaline conditions alleviated the metal toxicity. Besides, 1 mM manganese, which is non-cytotoxic, as judged by the growth of E. coli, synergistically elevated cobalt and nickel stress. However, the metal toxicity did not lead to oxidative stress in E. coli. On the other hand, we show that cobalt and nickel, but not manganese, reduced the rate of DNA replication to 50% within 2 hours. Interestingly, the metal ions promoted DNA double-strand breaks but did not induce SOS repair pathways, indicating that the metal ions could block SOS induction. To test this, we show that cobalt and nickel, but not manganese, suppressed the nalidixic acid-induced SOS response. Finally, using an in vitro assay system, we demonstrated that cobalt and nickel inhibit RecBCD function, which is essential for SOS induction. Therefore, our data indicate that cobalt and nickel affect DNA replication, damage DNA, and inhibit the SOS repair pathway to exert toxicity.
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Affiliation(s)
- Vineet Kumar
- CSIR-Institute of Microbial Technology, Sector 39-A, Chandigarh 160036, India.
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24
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Furrer S, Scherer Hofmeier K, Grize L, Bircher AJ. Metal hypersensitivity in patients with orthopaedic implant complications-A retrospective clinical study. Contact Dermatitis 2018; 79:91-98. [PMID: 29888396 DOI: 10.1111/cod.13032] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/15/2018] [Accepted: 04/19/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hypersensitivity to metals as a cause of implant-related complications has been a subject of controversy. Projections indicate an increase in the frequency of joint replacements of between 300% and 600% by the year 2030; therefore, this issue is of considerable interest. OBJECTIVE To evaluate sensitization to implant materials in patients with implant-related complications, to identify allergens, and to clarify whether hypersensitivity is a relevant cause. METHODS Patients with implant-related complications or a positive history of contact allergy and planned total joint replacements referred for allergological investigation between 2004 and 2017 were retrospectively analysed. RESULTS In total, 311 patients were included. A positive patch test reaction to a metal was seen in 64.4% of preoperative patients and in 54.6% of patients with implant-related complications. Common alloy metals such as cobalt, chromium and titanium gave positive reactions in up to 2.9% of patients with implant-related complications. None of the patients with skin changes had a positive patch test reaction to an implant metal. CONCLUSION Other factors, such as the type of replaced joint and mechanical stress, seem to be more relevant for implant-related complications. Sensitization to metals or other materials seems to rarely play a role, and is overestimated.
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Affiliation(s)
- Stefan Furrer
- Department of Dermatology, Allergy Unit, University Hospital, Basel, Switzerland
| | | | - Leticia Grize
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Andreas J Bircher
- Department of Dermatology, Allergy Unit, University Hospital, Basel, Switzerland.,University of Basel, Basel, Switzerland
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