Pleomorphic clinical spectrum of metallosis in total hip arthroplasty

Elevated Titanium Levels After Revision Total Hip Caused by Previously Unreported Mechanism

INTRODUCTION

Metallosis from total hip arthroplasty is usually due to trunnionosis and is associated with elevated serum cobalt and chromium levels. Titanium levels usually remain normal.

METHODS

Here, we report two rare cases of elevated titanium levels, both with the same mechanism, which is a previously unreported cause of titanium metallosis.

RESULTS

In these cases, contact between cables and the titanium stem were the source.

DISCUSSION

Reports of isolated high titanium levels associated with total hip arthroplasty are rare. These cases illustrate a new mechanism from which this situation may arise.

Metal-on-Metal Hip Arthroplasty: A Comprehensive Review of the Current Literature

Metal-on-metal (MoM) total hip arthroplasty has been widely used since the end of the 20th century, although rates have now decreased due to concerns regarding adverse reactions and failure rates. The MoM implant has been replaced with other materials, such as ceramic-on-ceramic (CoC) and metal-on-polyethylene (MoP). This literature review looks at the past and present use of MoM prostheses to assess whether the turn away from MoM use is justified. Online literature searches were performed on PubMed, Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), and Web of Science online databases using the search terms "MoM and (ARMD and ALVAL)" (ARMD: adverse reaction to metal debris; ALVAL: aseptic lymphocyte-dominant vasculitis-associated lesion). A total of 64 relevant titles were included in the review. Although risk factors for adverse reactions and the causes of ARMD are generally agreed upon, more work is required to further understand the specific thresholds of blood metal ion levels that can be used to consistently identify ARMD and excessive metal wear-debris in patients who have not had their MoM implants revised. Metal-on-metal devices are not an acceptable option for total hip arthroplasties (THAs) in their current formulation due to the high rate and risk of ARMD. Some MoM hip resurfacing operations are appropriate for very carefully selected patients who are fully aware of the risks posed by the implant. It is recommended that device-specific thresholds for metal ion levels be developed to identify patients at risk of ARMD locally and systemically while using auxiliary tools to assist diagnosis, such as metal artefact reduction sequences (MARS)-MRI and hip scoring tools. Further work should investigate device-specific blood metal ion levels, the systemic effects of raised metal ion concentrations secondary to MoM arthroprosthetic wear, and the potential risks of ARMD caused by wear from tapered stems (including the implications this has for patients with CoC and MoP prostheses).

Metallosis in Total Hip Arthroplasty

» Metallosis is a rare but significant complication that can occur after total hip arthroplasty (THA) for a variety of reasons but most commonly in patients with metal-on-metal implants.» It is characterized by the visible staining, necrosis, and fibrosis of the periprosthetic soft tissues, along with the variable presence of aseptic cysts and solid soft tissue masses called pseudotumors secondary to the corrosion and deposition of metal debris.» Metallosis can present with a spectrum of complications ranging from pain and inflammation to more severe symptoms such as osteolysis, soft tissue damage, and pseudotumor formation.» Workup of metallosis includes a clinical evaluation of the patient's symptoms, imaging studies, serum metal-ion levels, and intraoperative visualization of the staining of tissues. Inflammatory markers such as erythrocyte sedimentation rate and C-reactive protein along with intraoperative frozen slice analysis may be useful in certain cases to rule out concurrent periprosthetic joint infection.» Management depends on the severity and extent of the condition; however, revision THA is often required to prevent rapid progression of bone loss and tissue necrosis.

Metallosis and Nonunion: A Case Series and Literature Review

Metallosis, defined as the presence of free metal particles in the tissue, including bone and soft tissue, is a rare phenomenon seen in orthopedic practice. It is more commonly seen in arthroplasty surgeries, but its occurrence in the presence of other metal implants is also well recognized. Multiple hypotheses are suggested to explain the genesis of metallosis, but it is traditionally believed that abnormal contact between the metal surfaces leads to abrasive wear causing the release of metal particles into the surrounding tissue eliciting foreign body reactions from the body's immune system. The consequences can be local effects, which can be asymptomatic soft tissue lesions, or lead to significant osteolysis, tissue necrosis, joint effusion, and large soft tissue masses, causing secondary pathological effects. The systemic distribution of these metal particles can also contribute to the clinical picture. The literature contains multiple case reports of metallosis following arthroplasty surgeries, but there is limited information on metallosis resulting from osteosynthesis of fractures. In this review, we are presenting our experience with a few patients who developed nonunion following the index surgeries and on revision were found to have metallosis as well. It is difficult to postulate whether metallosis was contributory to the nonunion or the other way around or whether the occurrence of nonunion in face of metallosis was a pure coincidence. Additionally, one of our patients had a positive intraoperative culture, further complicating the picture. In addition to the case series, we present a succinct review of the literature on metallosis found in previous studies.

Surgical management of hip prosthetic failure in metallosis: A case series and literature review

Local and remote complications can be observed in hip prosthesis failures associated with metallosis. Structural changes in the periprosthetic bone and soft tissues may not always be precisely assessed preoperatively due to metal artifacts. The unpredictability of the damage extension, potentially leading to complex and insidious surgeries, requires the availability of alternative surgical plan(s) for the reconstruction of the joint. The aim of the study is to present and analyze, with the literature data support, practical tips for the revision of the prosthetic components, the management of ARMD and of intraoperative complications in the unusual scenario of metallosis.

Revealing Inflammatory Indications Induced by Titanium Alloy Wear Debris in Periprosthetic Tissue by Label-Free Correlative High-Resolution Ion, Electron and Optical Microspectroscopy

The metallic-associated adverse local tissue reactions (ALTR) and events accompanying worn-broken implant materials are still poorly understood on the subcellular and molecular level. Current immunohistochemical techniques lack spatial resolution and chemical sensitivity to investigate causal relations between material and biological response on submicron and even nanoscale. In our study, new insights of titanium alloy debris-tissue interaction were revealed by the implementation of label-free high-resolution correlative microscopy approaches. We have successfully characterized its chemical and biological impact on the periprosthetic tissue obtained at revision surgery of a fractured titanium-alloy modular neck of a patient with hip osteoarthritis. We applied a combination of photon, electron and ion beam micro-spectroscopy techniques, including hybrid optical fluorescence and reflectance micro-spectroscopy, scanning electron microscopy (SEM), Energy-dispersive X-ray Spectroscopy (EDS), helium ion microscopy (HIM) and micro-particle-induced X-ray emission (micro-PIXE). Micron-sized wear debris were found as the main cause of the tissue oxidative stress exhibited through lipopigments accumulation in the nearby lysosome. This may explain the indications of chronic inflammation from prior histologic examination. Furthermore, insights on extensive fretting and corrosion of the debris on nm scale and a quantitative measure of significant Al and V release into the tissue together with hydroxyapatite-like layer formation particularly bound to the regions with the highest Al content were revealed. The functional and structural information obtained at molecular and subcellular level contributes to a better understanding of the macroscopic inflammatory processes observed in the tissue level. The established label-free correlative microscopy approach can efficiently be adopted to study any other clinical cases related to ALTR.

The early- to medium-term results of a hemispherical, porous coated acetabular shell with multiple different bearing combinations are excellent with the exception of metal-on-metal

PURPOSE

This study prospectively reports survivorship and radiographic and clinical outcomes following primary elective total hip arthroplasty (THA) using a novel single hemispherical, porous-coated acetabular cup with five different bearing combinations and a minimum of five year follow-up.

METHODS

Continuing post-market release monitoring of this cup, we prospectively enrolled 108 patients (121 THA) between 2009 and 2015. We followed this cohort by examining survivorship, in addition to clinical and radiological outcomes for metal-on-metal (MoM) compared with non-MoM bearing combinations (ceramic-on-ceramic, oxinium-on-polyethylene, ceramic-on-metal, and metal-on-polyethylene).

RESULTS

All 108 (121 hips) patients were followed up. Average age at time of surgery was 45.1 years (range 19 to 71 years) of which 42.1% were males. A total of seven (5.8%) cups were revised, all of which were MoM. No osteolysis was observed in any of the patients at the latest visit with a mean follow-up of 9.1 ± 1.7 years (range 4.4-10.7 years). With MoM excluded, survivorship of the cup at five  years is 97.8%. Survivorship for MoM implants was 90.0%. Validated hip scores showed significant improvements for all bearing types and no significant difference between groups at latest follow-up (p = 0.614). There was no cup migration with any bearing surface.

CONCLUSION

This cup showed excellent survivorship at five year follow-up, except for patients receiving a MoM articulation. While there were concerns over the early survivorship of this cup, our cohort and joint registry data confirm excellent outcomes.

Metal on metal hip arthroplasty surveillance at a tertiary centre: design, patients' adherence, and cost analysis

PURPOSE

Metal-on-metal (MOM) bearings may carry higher than expected revision rates and serious complications: an appropriate surveillance may be advocated. Aims of this paper were to (1) present the biennial experience of MOM surveillance in a tertiary centre, (2) describe the patients' adherence to monitoring, and (3) analyze the costs of the surveillance METHODS: The design of MOM surveillance was developed according to the guidelines of the Italian Society of Orthopaedics and Traumatology. The adherence to every follow-up was expressed as raw numbers and percentages. A cost analysis (direct and indirect costs) was conducted and projected in a five year time span.

RESULTS

About 61.1% of patients adhered to the first step of the surveillance, and 13.5% answered to a specific questionnaire about MOM implant. About 36.2% of the patients participated for the annual follow-up, and 18.1% entered the six month follow-up program. Of the implants, 2.5% required a revision. A two year surveillance costs €45,520.30, €236,443.98 (57.7%) including revisions. Five-year projected costs will be €23.113,64 (5.6%). Hospital indirect costs, including personnel working days, were €150,392.30 (36.7%). The estimated economic burden for seven years will be €409,949.92 (direct € 259,557.62, indirect €150,392.30).

CONCLUSION

Patients' adherence to MOM surveillance is modest and the rate of dropouts seems not to stop over the time. Most of the expenses are due to revision surgeries, as well as indirect costs. Economy of scale may be suggested to reduce the costs, involving as much MOM population as possible.

A Case Report of Metallosis With a Failed Distal Femur Plate

Metallosis is a very rare condition that poses a diagnostic challenge. Its precise incidence is not known and the condition should be suspected in patients who present with the clinical signs and symptoms discussed below. In particular, physicians and surgeons should pay special attention to whether metal prosthesis has been used for fracture repair or joint function. Here we report the case of a 40-year-old male who presented at an orthopedic surgery outpatient department in a tertiary care hospital with pain in the right distal thigh that had been ongoing for three months and swelling that had been ongoing for two months. According to the patient, he had received an operation for a right-sided distal femur fracture that was fixed with plate at a different hospital one year prior. Despite receiving all the appropriate physical exams and labs, and getting a radiologic workup, the diagnosis was unclear, and ultimately surgical exploration was conducted, which led to the diagnosis of metallosis. Although metallosis is a well-known complication, due to its rarity, physicians and surgeons often forget to keep metallosis as a differential that leads to diagnostic difficulties.

Resumption of physical activity and sport after knee replacement

Purpose

to assess the resumption of physical activity after knee replacement.

Methods

retrospective study.

Results

118 patients were included in the final analysis. A resumption of >93% of the activities performed before surgery was observed. Logistic regression analysis did not show any significant associations between postoperatory activity and epidemiological and clinical variables except the function perceived by the patient.

Conclusions

the resumption of physical activity and sport is a paramount expectation for active patients. A clearer definition of physical activity and sports realistically achievable after a knee prosthesis is necessary but not yet fully available.

Severe metallosis-related osteolysis as a cause of failure after total knee replacement

BACKGROUND

Metallosis is a syndrome of metal-induced synovitis caused by friction between two metal surfaces. In contrast to the hip joint after resurfacing arthroplasty or metal-on-metal (MoM) total hip replacement, metallosis of the knee is extremely rare.

MATERIALS

We describe 4 patients who underwent revision total knee replacement because of disabling pain and implant loosening after a mean time of 21 (range: 13-30) years of knee replacement surgery. They were all females with a mean age of 79 (range: 75-82) years. Septic loosening was excluded through microbiological examination and synovial fluid analysis.

RESULTS

Direct metal-on-metal contact at the tibiofemoral interface was confirmed intraoperatively in all cases. All knees showed severe metallosis with advanced osteolysis and pseudotumor formation. In one knee there was a complete fracture of the tibial tray. All patients had a one-stage revision surgery with implant removal, profound synovectomy and implantation of a constrained modular revision knee system. Long modular stems with offset adapters, wedges and/or blocks were used in all cases.

CONCLUSION

Metallosis-associated osteolysis should be suspected in cases with radiologically evident polyethylene wear after knee replacement. Recognizing that revision arthroplasty is very technically demanding in such cases, surgeons should have a back-up with modular revision components and a ready access to reconstructive options at this revision setting.

[A minimally invasive technique for removal of a firmly fixed Küntscher nail in primary hip arthroplasty]

This article reports the case of an 80-year-old male patient who presented to this hospital with symptomatic arthritis of the left hip. The special feature of this case was a Küntscher nail in the left femur that had been in situ for more than 50 years. Before implantation of the total hip arthroplasty the nail first had to be removed. As the Küntscher nail is a rarity nowadays there is no standardized procedure for the removal of such a nail. This case report describes a minimally invasive possibility to remove a Küntscher nail in total hip arthroplasty.