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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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Abstract
In the United States, cervical total disk arthroplasty (TDA) is US Federal Drug Administration (FDA) approved for use in both 1 and 2-level constructions for cervical disk disease resulting in myelopathy and/or radiculopathy. TDA designs vary in form, function, material composition, and even performance in?vivo. However, the therapeutic goals are the same: to remove the painful degenerative/damaged elements of the intervertebral discoligamenous joint complex, to preserve or restore the natural range of spinal motion, and to mitigate stresses on adjacent spinal segments, thereby theoretically limiting adjacent segment disease (ASDis). Cervical vertebrae exhibit complex, coupled motions that can be difficult to artificially replicate. Commonly available TDA designs include ball-and-socket rotation-only prostheses, ball-and-trough rotation and anterior-posterior translational prostheses, as well as unconstrained elastomeric disks that can rotate and translate freely in all directions. Each design has its respective advantages and disadvantages. At this time, available clinical evidence does not favor 1 design philosophy over another. The superiority of cervical TDA over the gold-standard anterior cervical discectomy and fusion is a subject of great controversy. Although most studies agree that cervical TDA is at least as effective as anterior cervical discectomy and fusion at reducing or eliminating preoperative pain and neurological symptoms, the clinical benefits of motion preservation- that is, reduced incidence of ASDis-are far less clear. Several short-to-mid-term studies suggest that disk arthroplasty reduces the radiographic incidence of adjacent segment degeneration; however, the degree to which this is clinically significant is disputed. At this time, TDA has not been clearly demonstrated to reduce symptomatic?ASDis.
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Corrosion of Harrington rod in idiopathic scoliosis: long-term effects. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017. [PMID: 28624897 DOI: 10.1007/s00586-017-5183-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Metal implants have been used to treat adolescent idiopathic scoliosis since the 1960s. Only recently, however, it has the issue of metal-bone breakdown secondary to metal corrosion in situ come to light, raising concerns of possible long-term complications from the resulting metallosis and inflammation of spinal tissues. We present a case of a patient with neurological deficit, pain, and disability with Harrington rod in place for over 30 years, to bring attention to the issue of bio-corrosion of metal implants and its effect on human tissue. We call attention to the need for protocols to better diagnose and treat these patients. METHODS We provide a complete review of the history and clinical manifestations as well as serum metal, X-ray, and CT/myelogram test results. RESULTS A 52-year-old female with spinal fusion and Harrington rod presents with pain, lymphedema, disability, and neurological deficits including thoracic outlet syndrome, hyperreflexia, peripheral muscle weakness and atrophy, hypertonicity, Raynaud's phenomenon, and balance and gait abnormalities. Serum chromium levels were elevated (26.73 nmol). X-rays showed no evidence of rod breakdown. Serial X-rays can demonstrate subtle corrosive changes but were not available. Adhesive arachnoiditis was diagnosed via CT/myelogram. CONCLUSION We hypothesize that bio-corrosion is present in this case and that it is associated with intraspinal metallosis. Trauma secondary to a motor vehicle accident, as well as arachnoiditis, and their possible effects on this case are outlined. Challenges in proper diagnosis and management are discussed.
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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.
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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.
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Shichang L, Yueming S, Limin L, Lei W, Zhongjie Z, Chunguang Z, Xi Y. Clinical and radiologic comparison of dynamic cervical implant arthroplasty and cervical total disc replacement for single-level cervical degenerative disc disease. J Clin Neurosci 2016; 27:102-9. [PMID: 26928156 DOI: 10.1016/j.jocn.2015.05.072] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 05/11/2015] [Accepted: 05/31/2015] [Indexed: 02/05/2023]
Abstract
Anterior cervical discectomy and fusion, to date the most successful spine procedure for the surgical treatment of cervical radiculopathy, has limitations that have led to the development of non-fusion cervical procedures, such as cervical total disc replacement (TDR) and dynamic cervical implant (DCI) arthroplasty. We compared the clinical and radiological results of DCI and cervical TDR for the treatment of single-level cervical degenerative disc disease in Chinese patients. A retrospective review of 179 patients with cervical spondylotic myelopathy who underwent DCI or TDR between April 2010 and October 2012 was conducted, and 152 consecutive patients (67 patients single-level DCI and 85 single-level TDR) who completed at least 2years of follow-up were included. Clinical and radiological assessments were performed preoperatively and at 1week and 3, 6, 12, and 24months postoperatively. The most common operative level was C5/C6 (49.3%). The differences in blood loss, duration of surgery, and duration of hospitalization were not statistically significant. The Japanese Orthopaedic Association scale, Visual Analog Scale, Neck Disability Index, and Short Form-36 scores improved significantly after surgery in both the DCI and TDR groups (P<0.05), but the differences were not statistically significant at the final follow-up. The rate of occurrence of heterotopic ossification was 22.4% and 28.2% in the DCI and TDR groups, respectively. As an effective non-fusion technique, DCI is a more economical procedure. Further prospective, randomized studies with long-term follow-up periods are needed to determine the long-term effects.
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Affiliation(s)
- Liu Shichang
- Department of Orthopedics, West China Hospital of Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan 610041, China
| | - Song Yueming
- Department of Orthopedics, West China Hospital of Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan 610041, China
| | - Liu Limin
- Department of Orthopedics, West China Hospital of Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan 610041, China.
| | - Wang Lei
- Department of Orthopedics, West China Hospital of Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan 610041, China
| | - Zhou Zhongjie
- Department of Orthopedics, West China Hospital of Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan 610041, China
| | - Zhou Chunguang
- Department of Orthopedics, West China Hospital of Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan 610041, China
| | - Yang Xi
- Department of Orthopedics, West China Hospital of Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan 610041, China
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Abstract
PURPOSE The primary goal of this Policy Statement is to educate patients, physicians, medical providers, reviewers, adjustors, case managers, insurers, and all others involved or affected by insurance coverage decisions regarding lumbar disc replacement surgery. PROCEDURES This Policy Statement was developed by a panel of physicians selected by the Board of Directors of ISASS for their expertise and experience with lumbar TDR. The panel's recommendation was entirely based on the best evidence-based scientific research available regarding the safety and effectiveness of lumbar TDR.
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Which design and biomaterial factors affect clinical wear performance of total disc replacements? A systematic review. Clin Orthop Relat Res 2014; 472:3759-69. [PMID: 25002211 PMCID: PMC4397740 DOI: 10.1007/s11999-014-3751-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Total disc replacement was clinically introduced to reduce pain and preserve segmental motion of the lumbar and cervical spine. Previous case studies have reported on the wear and adverse local tissue reactions around artificial prostheses, but it is unclear how design and biomaterials affect clinical outcomes. QUESTIONS/PURPOSES Which design and material factors are associated with differences in clinical wear performance (implant wear and periprosthetic tissue response) of (1) lumbar and (2) cervical total disc replacements? METHODS We performed a systematic review on the topics of implant wear and periprosthetic tissue response using an advanced search in MEDLINE and Scopus electronic databases. Of the 340 references identified, 33 were retrieved for full-text evaluation, from which 16 papers met the inclusion criteria (12 on lumbar disc replacement and five on cervical disc replacement; one of the included studies reported on both lumbar and cervical disc replacement), which involved semiquantitative analysis of wear and adverse local tissue reactions along with a description of the device used. An additional three papers were located by searching bibliographies of key articles. There were seven case reports, three case series, two case-control studies, and seven analytical studies. The Methodological Index for Non-randomized Studies (MINORS) Scale was used to score case series and case-control studies, which yielded mean scores of 10.3 of 16 and 17.5 of 24, respectively. In general, the case series (three) and case-control (two) studies were of good quality. RESULTS In lumbar regions, metal-on-polymer devices with mobile-bearing designs consistently generated small and large polymeric wear debris, triggering periprosthetic tissue activation of macrophages and giant cells, respectively. In the cervical regions, metal-on-polymer devices with fixed-bearing designs had similar outcomes. All metal-on-metal constructs tended to generate small metallic wear debris, which typically triggered an adaptive immune response of predominantly activated lymphocytes. There were no retrieval studies on one-piece prostheses. CONCLUSIONS This review provides evidence that design and biomaterials affect the type of wear and inflammation. However, clinical study design, followup, and analytical techniques differ among investigations, preventing us from drawing firm conclusions about the relationship between implant design and wear performance for both cervical and lumbar total disc replacement.
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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.
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Pearcy MJ. Artificial lumbar intervertebral disc replacement: accepted practice or experimental surgery? Expert Rev Med Devices 2014; 7:855-60. [DOI: 10.1586/erd.10.60] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Assessment of epidural versus intradiscal biocompatibility of PEEK implant debris: an in vivo rabbit model. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:2740-51. [PMID: 23996005 DOI: 10.1007/s00586-013-2904-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/25/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To understand the relative histopathological effects of PEEK particulate debris when applied within the epidural versus the intervertebral disc space. We hypothesized that due to the avascular nature of the intervertebral disc acting as a barrier to immune cells, the intradiscal response would be less than the epidural response. METHODS The inflammatory effects of clinically relevant doses (3 mg/5-kg rabbit) and sizes (1.15 µm diameter) of PEEK implant debris were assed when placed dry on epidural and intradiscal tissues in an in vivo rabbit model. The size of the particulate was based on wear particulate analysis of wear debris generated from simulator wear testing of PEEK spinal disc arthroplasty devices. Local and systemic gross histology was evaluated at the 3- and 6-month time points. Quantitative immunohistochemistry of local tissues was used to quantify the common inflammatory mediators TNF-α, IL-1β, and IL-6. RESULTS Both treatments did not alter the normal appearance of the dura mater and vascular structures; however, limited epidural fibrosis was observed. Epidural challenge of PEEK particles resulted in a significant (30 %) increase (p < 0.007) in TNF-α and IL-1β at both 3 and 6 months compared to that of controls, and IL-6 at 6 months (p < 0.0001). Intradiscal challenge of PEEK particles resulted in a significant increase in IL-1β, IL-6 and TNF-α at 6-months post-challenge (p ≤ 0.03). However, overall there were only moderate increases in the relative amount of these cytokines when compared with surgical controls (10-20 %). In contrast, epidural challenge resulted in a 50-100 % increase. CONCLUSIONS The results of this study are similar to past investigations of PEEK, whose results have not been shown to elicit an aggressive immune response. The degree to which these results will translate to the clinical environment remains to be established, but the pattern of subtle elevations in inflammatory cytokines indicated both a mild persistence of responses to PEEK debris, and that intradiscal implant debris will likely result in less inflammation than epidural implant debris.
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Moghadas P, Mahomed A, Hukins DWL, Shepherd DET. Wear in metal-on-metal total disc arthroplasty. Proc Inst Mech Eng H 2013; 227:356-61. [DOI: 10.1177/0954411912471768] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The wear of a model metal-on-metal ball-and-socket total disc arthroplasty was measured in a simulator. The ball had a radius of 10 mm, and there was a radial clearance between ball and socket of 0.015 mm. The model was subjected to simultaneous flexion–extension, lateral bending, axial rotation (frequency: 1 Hz) and compression (frequency: 2 Hz, maximum load: 2 kN). Throughout the tests, the models were immersed in calf serum diluted to a concentration of 15 g protein per litre, at a controlled temperature of 37 °C. Tests were performed on three models. At regular intervals (0, 0.5, 1, 2, 3, 4 and 5 million cycles), mass and surface roughness were determined; mass measurements were converted into the volume lost as a result of wear. All measurements were repeated six times. Wear occurred in two stages. In the first stage (duration about 1 million cycles), there was a linear wear rate of 2.01 ± 0.04 mm3 per million cycles; in the second stage, there was a linear wear rate of 0.76 ± 0.02 mm3 per million cycles. Surface roughness increased linearly in the first million cycles and then continued to increase linearly but more slowly.
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Affiliation(s)
- Parshia Moghadas
- School of Mechanical Engineering, University of Birmingham, Birmingham, UK
| | - Aziza Mahomed
- School of Mechanical Engineering, University of Birmingham, Birmingham, UK
| | - David WL Hukins
- School of Mechanical Engineering, University of Birmingham, Birmingham, UK
| | - Duncan ET Shepherd
- School of Mechanical Engineering, University of Birmingham, Birmingham, UK
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Prospective study on serum metal levels in patients with metal-on-metal lumbar disc arthroplasty. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012. [PMID: 23179981 DOI: 10.1007/s00586-012-2581-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Metal-on-metal total disc replacement is a recent alternative treatment for degenerative disc disease. Wear and corrosion of these implants can lead to local and systemic transport of metal debris. This prospective longitudinal study examined the serum chromium and cobalt levels in 24 patients with cobalt-chromium alloy metal-on-metal lumbar disc replacements. METHODS Serum was assayed for chromium (Cr) and cobalt (Co) using high-resolution inductively-coupled plasma-mass spectrometry. Detection limits were 0.015 ng/mL for Cr and 0.04 ng/mL for Co. RESULTS Median serum Co levels at pre-op, 3, 6, 12, 24, and 36-months post-op were 0.10, 1.03, 0.96, 0.98, 0.67, and 0.52 ng/mL, respectively. Median serum Cr levels were 0.06, 0.49, 0.65, 0.43, 0.52, and 0.50 ng/mL, respectively. CONCLUSION In general, these results indicated that serum Co and Cr levels are elevated at all postoperative time points and are of the same order of magnitude as those observed in well-functioning metal-on-metal surface replacements of the hip and in metal-on-metal total hip replacements at similar postoperative time points.
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Are periprosthetic tissue reactions observed after revision of total disc replacement comparable to the reactions observed after total hip or knee revision surgery? Spine (Phila Pa 1976) 2012; 37:150-9. [PMID: 21336235 PMCID: PMC3145819 DOI: 10.1097/brs.0b013e3182154c22] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Comparative study. OBJECTIVE To compare periprosthetic tissue reactions observed after total disc replacement (TDR), total hip arthroplasty (THA), and total knee arthroplasty (TKA) revision surgery. SUMMARY OF BACKGROUND DATA Prosthetic wear debris leading to particle disease, followed by osteolysis, is often observed after THA and TKA. Although the presence of polyethylene (PE) particles and periprosthetic inflammation after TDR has been proven recently, osteolysis is rarely observed. The clinical relevance of PE wear debris in the spine remains poorly understood. METHODS The number, size, and shape of PE particles, as well as quantity and type of inflammatory cells in periprosthetic tissue retrieved during CHARITÉ TDR (n = 22), THA (n = 10), and TKA (n = 4) revision surgery were compared. Tissue samples were stained with hematoxylin/eosin and examined by using light microscopy with bright field and polarized light. RESULTS After THA, large numbers of PE particles of size less than 6 μm were observed, which were mainly phagocytosed by macrophages. The TKA group had a broad size range with many larger PE particles and more giant cells. In TDR, the size range was similar to that observed in TKA. However, the smallest particles were the most prevalent with 75% of the particles being less than 6 μm, as seen in revision THA. In TDR, both macrophages and giant cells were present with a higher number of macrophages. CONCLUSION Both small and large PE particles are present after TDR revision surgery compatible with both THA and TKA wear patterns. The similarities between periprosthetic tissue reactions in the different groups may give more insight into the clinical relevance of PE particles and inflammatory cells in the lumbar spine. The current findings may help to improve TDR design as applied from technologies previously developed in THA and TKA with the goal of a longer survival of TDR.
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Qu X, Huang X, Dai K. Metal-on-metal or metal-on-polyethylene for total hip arthroplasty: a meta-analysis of prospective randomized studies. Arch Orthop Trauma Surg 2011; 131:1573-83. [PMID: 21643799 DOI: 10.1007/s00402-011-1325-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND There has been recent concern regarding the increased use of metal-on-metal total hip arthroplasty (MOM-THA) as an alternative to contemporary metal-on-polyethylene total hip arthroplasty (MOP-THA), and the choice remains controversial. We performed a meta-analysis to evaluate and compare metal ion concentrations, complications, reoperation rates, clinical outcomes and radiographic outcomes of MOM-THA and MOP-THA. METHODS We performed a systematic review of English and non-English articles identified from MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, PreMEDLINE and HealthSTAR. Metal ion concentrations, complications, reoperation rates and other outcomes of MOM bearings were compared with MOP bearings in THA based on relative risks, mean differences and standardized mean difference statistics. RESULTS Eight prospective randomized trials were identified from 1,075 citations. Our results demonstrated significantly elevated erythrocyte, serum and urine levels of metal ions (cobalt and chromium) among patients who received MOM-THA. No significant differences in titanium concentrations or total complication or reoperation rates were found between MOM-THA and MOP-THA. Clinical function scores and radiographic evaluations were similar between the two groups. CONCLUSIONS This analysis found insufficient evidence to identify any clinical advantage of MOM-THA compared with MOP-THA. Although cobalt and chromium concentrations were elevated after MOM-THA, there were no significant differences in total complication rates (including all-case mortality) between the two groups in the short- to mid-term follow-up period. The MOM bearing option for THA should be used with caution.
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Affiliation(s)
- Xinhua Qu
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011, People's Republic of China
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Sakellariou VI, Atsali E, Starantzis K, Batistaki C, Brozou T, Pantos P, Stathopoulos K, Soultanis K. Postoperative spinal infection mimicking systemic vasculitis with titanium-spinal implants. SCOLIOSIS 2011; 6:20. [PMID: 21914179 PMCID: PMC3182133 DOI: 10.1186/1748-7161-6-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 09/13/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Secondary systemic vasculitis after posterior spinal fusion surgery is rare. It is usually related to over-reaction of immune-system, to genetic factors, toxicity, infection or metal allergies. CASE DESCRIPTION A 14 year-old girl with a history of extended posterior spinal fusion due to idiopathic scoliosis presented to our department with diffuse erythema and nephritis (macroscopic hemuresis and proteinuria) 5 months post surgery. The surgical trauma had no signs of inflammation or infection. The blood markers ESR and CRP were increased. Skin tests were positive for nickel allergy, which is a content of titanium alloy. The patient received corticosteroids systematically (hydrocortisone 10 mg) for 6 months, leading to total recess of skin and systemic reaction. However, a palpable mass close to the surgical wound raised the suspicion of a late infection. The patient had a second surgery consisting of surgical debridement and one stage revision of posterior spinal instrumentation. Intraoperative cultures were positive to Staphylococcus aureus. Intravenous antibiotics were administered. The patient is now free of symptoms 24 months post revision surgery without any signs of recurrence of either vasculitis or infection. LITERATURE REVIEW Systemic vasculitis after spinal surgery is exceptionally rare. Causative factors are broad and sometimes controversial. In general, it is associated with allergy to metal ions. This is usually addressed with metal on metal total hip bearings. In spinal surgery, titanium implants are considered to be inert and only few reports have presented cases with systemic vasculitides. Therefore, other etiologies of immune over-reaction should always be considered, such as drug toxicity, infection, or genetic predisposition. PURPOSES AND CLINICAL RELEVANCE Our purpose was to highlight the difficulties during the diagnostic work-up for systemic vasculitis and management in cases of posterior spinal surgery.
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Affiliation(s)
- Vasileios I Sakellariou
- First Department of Orthopaedics, School of Medicine, University of Athens, Attikon, University General Hospital, Chaidari, Greece
| | - Erato Atsali
- Third Department of Paediatrics, School of Medicine, University of Athens, Attikon, University General Hospital, Chaidari, Greece
| | - Konstantinos Starantzis
- First Department of Orthopaedics, School of Medicine, University of Athens, Attikon, University General Hospital, Chaidari, Greece
| | - Chrysanthi Batistaki
- Second Department of Anaesthesiology, School of Medicine, University of Athens, Attikon, University General Hospital, Chaidari, Greece
| | - Triantafyllia Brozou
- Third Department of Paediatrics, School of Medicine, University of Athens, Attikon, University General Hospital, Chaidari, Greece
| | - Panayiotis Pantos
- First Department of Orthopaedics, School of Medicine, University of Athens, Attikon, University General Hospital, Chaidari, Greece
| | - Konstantinos Stathopoulos
- First Department of Orthopaedics, School of Medicine, University of Athens, Attikon, University General Hospital, Chaidari, Greece
| | - Konstantinos Soultanis
- First Department of Orthopaedics, School of Medicine, University of Athens, Attikon, University General Hospital, Chaidari, Greece
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Serum metal ion levels after rotating-hinge knee arthroplasty: comparison between a standard device and a megaprosthesis. INTERNATIONAL ORTHOPAEDICS 2011; 36:539-44. [PMID: 21755331 DOI: 10.1007/s00264-011-1317-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 06/24/2011] [Indexed: 01/08/2023]
Abstract
PURPOSE The effects of systemic metal ion exposure in patients with implants made of common prosthetic alloys continue to be a matter of concern. The aim of the study was to determine the measurement values of cobalt (Co), chromium (Cr) and molybdenum (Mo) in serum following rotating-hinge knee arthroplasty. METHODS Blood was taken from 25 patients [mean follow-up 35 (range nine to 67) months] treated with megaprostheses (n=17) or standard rotating-hinge devices (n=8) and analysed using electrothermal graphite furnace atomic absorption spectrometry (ET-ASS). RESULTS Determining the concentrations of metal ions following rotating-hinge knee arthroplasty revealed increments for Co and Cr but not Mo. Metal ion release was significantly higher in patients with megaprostheses compared to a standard rotating-hinge knee device (Co p=0,024; Cr p=0.025). CONCLUSION The authors believe there might be an additional metal ion release from the surface of the prosthesis and not only from the articulating surfaces because, in cases of rotating-hinge knee prosthesis, there is a metal-on-polyethylene articulation and not a direct metal-on-metal junction. Nevertheless, long-term studies are required to determine adverse effects of Co, Cr and Mo following total hip replacement and total knee arthroplasty.
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Bisseling P, Zeilstra DJ, Hol AM, van Susante JLC. Metal ion levels in patients with a lumbar metal-on-metal total disc replacement. ACTA ACUST UNITED AC 2011; 93:949-54. [DOI: 10.1302/0301-620x.93b7.26392] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The purpose of this study was to evaluate whether concerns about the release of metal ions in metal-on-metal total hip replacements (THR) should be extended to patients with metal-bearing total disc replacements (TDR). Cobalt and chromium levels in whole blood and serum were measured in ten patients with a single-level TDR after a mean follow-up of 34.5 months (13 to 61) using inductively-coupled plasma mass spectrometry. These metal ion levels were compared with pre-operative control levels in 81 patients and with metal ion levels 12 months after metal-on-metal THR (n = 21) and resurfacing hip replacement (n = 36). Flexion-extension radiographs were used to verify movement of the TDR. Cobalt levels in whole blood and serum were significantly lower in the TDR group than in either the THR (p = 0.007) or the resurfacing group (p < 0.001). Both chromium levels were also significantly lower after TDR versus hip resurfacing (p < 0.001), whereas compared with THR this difference was only significant for serum levels (p = 0.008). All metal ion levels in the THR and resurfacing groups were significantly higher than in the control group (p < 0.001). In the TDR group only cobalt in whole blood appeared to be significantly higher (p < 0.001). The median range of movement of the TDR was 15.5° (10° to 22°). These results suggest that there is minimal cause for concern about high metal ion concentrations after TDR, as the levels appear to be only moderately elevated. However, spinal surgeons using a metal-on-metal TDR should still be aware of concerns expressed in the hip replacement literature about toxicity from elevated metal ion levels, and inform their patients appropriately.
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Affiliation(s)
- P. Bisseling
- Department of Orthopaedics, Rijnstate Hospital, Postbox 9555, 6800 TA Arnhem, The Netherlands
| | - D. J. Zeilstra
- Neurosurgical Centre, Isala Clinics, Postbox 10400, 8000 GK Zwolle, The Netherlands
| | - A. M. Hol
- Department of Orthopaedics, Rijnstate Hospital, Postbox 9555, 6800 TA Arnhem, The Netherlands
| | - J. L. C. van Susante
- Department of Orthopaedics, Rijnstate Hospital, Postbox 9555, 6800 TA Arnhem, The Netherlands
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Femoral neck resorption following hybrid metal-on-metal hip resurfacing arthroplasty: a radiological and biomechanical analysis. Arch Orthop Trauma Surg 2010; 130:1433-8. [PMID: 20213452 DOI: 10.1007/s00402-010-1070-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Indexed: 12/13/2022]
Abstract
INTRODUCTION With the resurgence of resurfacing hip arthroplasty complications such as femoral neck fracture and thinning have been identified. We therefore conducted a radiological and biomechanical evaluation of factors affecting femoral neck resorption following resurfacing hip arthroplasty (RHA). METHODS We retrospectively reviewed 61 resurfacing hip arthroplasties in 53 patients with a minimum of a 2-year follow-up. Data regarding age, gender, body mass index, indication for surgery, and component size was obtained from case records. Radiographic measurements were made from standardised digital AP pelvic radiographs. The neck shaft angle, stem shaft angle, and the varus-valgus femoral stem alignment were calculated. Changes in abductor/body moment arm, hip ratio, and cup-to-neck ratio were calculated from the pre-op, immediate post-op and 2 year post-operative radiographs. RESULTS Femoral neck thinning was identified in 98% of cases (60/61) and was greater than 10% in 59% (39/61). The mean change in component-to-neck ratio was 0.12 (0-0.44). No significant relationship was found between the amount of femoral neck resorption and patient age, BMI, gender, diagnosis, component size or orientation. A significant positive correlation was found between a change in abductor moment arm and femoral neck resorption (R = 0.575; p < 0.01). We also calculated that approximately one-third of the change in CNR could be explained by a change in abductor moment arm. From this we formulated the Pillai-Joseph equation to calculate projected thinning at 2 years from the initial post-operative radiograph (CNR difference = 0.094 × AMA difference + 0.129). CONCLUSIONS RHA significantly alters hip biomechanics and this may result in altered loading patterns with adaptive remodelling causing neck thinning. In order to minimise neck thinning care must be taken not to increase the abductor moment arm.
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Imanishi T, Hasegawa M, Sudo A. Serum metal ion levels after second-generation metal-on-metal total hip arthroplasty. Arch Orthop Trauma Surg 2010; 130:1447-50. [PMID: 20111868 DOI: 10.1007/s00402-010-1056-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Metal-on-metal bearings for total hip arthroplasty are increasing in popularity. However, metal ion toxicity, metal hypersensitivity, and metal carcinogenicity are the causes concern for patients with metal-on-metal hip replacement. We investigated serum levels of cobalt and chromium ions in patients with successfully implanted second-generation metal-on-metal total hip arthroplasty (THA) using PINNACLE-A (DePuy, Warsaw, IN, USA). MATERIALS AND METHODS Thirty-three patients underwent primary cementless THA with the use of a 36-mm femoral head PINNACLE-A with a metal-on-metal articulation. Blood samples were taken preoperatively, at 3 months, and at 1 year, and levels of cobalt and chromium were determined. RESULTS At 3 months, levels of both cobalt and chromium had increased significantly compared with preoperative levels. There were no significant differences between levels of either metal at 3 months and 1 year. CONCLUSION Patients with metal-on-metal THA had higher circulating levels of metal ions than before arthroplasty at 3 months, with no additional significant increases at 1 year in this study.
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Affiliation(s)
- Takao Imanishi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Abstract
BACKGROUND Biologic-reactivity to implant-debris is the primary determinant of long-term clinical performance. The following reviews: 1) the physical aspects of spinal-implant debris and 2) the local and systemic biologic responses to implant debris. METHODS Methods included are: 1) gravimetric wear analysis; 2) SEM and LALLS; 3) metal-ion analysis; 4) ELISA, toxicity testing, patch testing; and 5) metal-lymphocyte transformation testing (metal-LTT). RESULTS Wear and corrosion of spine-implants produce particles and ions. Particles (0.01-1000 μm) are generally submicron ( <1 µm). Wear rates of metal-on-polymer and metal-on-metal disc arthroplasties are approximately 2-20 and 1 mm(3)/yr, respectively. Metal-on-metal total disc replacement components have significant increases in circulating metal (less than 10-fold that of controls at 4 ppb-Co and 3 ppb-Cr or ng/mL). Debris reactivity is local and systemic. Local inflammation is caused primarily by ingestion of debris by local macrophages, which produce pro-inflammatory cytokines TNFα, IL-1β, IL-6, and PGE2. Systemic responses associated with implant-debris have been limited to hypersensitivity reactions. Elevated amounts of in the liver, spleen, etc of patients with failed TJA have not been associated with remote toxicological or carcinogenic pathology to date. Implant debris are differentially bioreactive. Greater numbers are pro-inflammatory; the smaller-sized debris are more bioreactive by virtue of their greater numbers (dose) for a given amount of implant mass loss (one 100-μm-diameter particle is equivalent in mass to 1 million 1-μm-diameter particles). Elongated particles are pro-inflammatory (ie, aspect ratio of greater than 3). Metal particles are more proinflammatory than polymers, ceteris paribus. CONCLUSION Spinal arthroplasty designs have been in use for more than 20 years internationally; therefore, concerns about neuropathology, toxicity, and carcinogenicity are mitigated. Debris-induced inflammation still depends on the individual and the type of debris. The consequence of debris-induced inflammation is continued; vigilance by physicians is recommended monitoring of spinal implants using physical exams and testing of metal content and bioreactivity, as is planning for the likelihood of revision in younger individuals.
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Affiliation(s)
- Nadim James Hallab
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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