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Pietrzak S, Marciniak W, Derkacz R, Matuszczak M, Kiljańczyk A, Baszuk P, Bryśkiewicz M, Sikorski A, Gronwald J, Słojewski M, Cybulski C, Gołąb A, Huzarski T, Dębniak T, Lener MR, Jakubowska A, Kluz T, Soroka M, Scott RJ, Lubiński J. Cobalt Serum Level as a Biomarker of Cause-Specific Survival among Prostate Cancer Patients. Cancers (Basel) 2024; 16:2618. [PMID: 39123346 PMCID: PMC11310964 DOI: 10.3390/cancers16152618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/15/2024] [Accepted: 07/20/2024] [Indexed: 08/12/2024] Open
Abstract
Prostate cancer is the most common cancer diagnosed in men and the second leading cause of death in male cancer patients. The WHO suggests that cobalt is involved in the carcinogenesis of prostate cancer. There are, however, no studies associating cobalt levels and prostate cancer patient survival. In this study, 261 Polish prostate cancer (n = 261) patients were recruited into a prospective cohort between 2009 and 2015. Serum cobalt levels were measured using ICP-MS after prostate cancer diagnosis and before treatment. All study participants were assigned into quartiles (QI-QIV) based on the distribution of serum cobalt levels among censored patients. Univariable and multivariable COX regression models were used to calculate hazard ratios (HRs) for each serum cobalt level quartile. We found a significant relationship between high serum cobalt levels and poor prostate cancer patient total survival (HR = 2.60; 95% CI: 1.17-5.82; p = 0.02). In relation to prostate cancer patients who died as a result of other non-cancer causes, the association with high levels of cobalt was even stronger (HR = 3.67; 95% CI: 1.03-13.00; p = 0.04). The impact of high serum cobalt levels on overall survival of prostate cancer-specific-related deaths was not statistically significant.
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Affiliation(s)
- Sandra Pietrzak
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
| | - Wojciech Marciniak
- Read-Gene, Grzepnica, ul. Alabastrowa 8, 72-003 Dobra (Szczecińska), Poland; (W.M.); (R.D.)
| | - Róża Derkacz
- Read-Gene, Grzepnica, ul. Alabastrowa 8, 72-003 Dobra (Szczecińska), Poland; (W.M.); (R.D.)
| | - Milena Matuszczak
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
| | - Adam Kiljańczyk
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
| | - Piotr Baszuk
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
- Read-Gene, Grzepnica, ul. Alabastrowa 8, 72-003 Dobra (Szczecińska), Poland; (W.M.); (R.D.)
| | - Marta Bryśkiewicz
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
- Read-Gene, Grzepnica, ul. Alabastrowa 8, 72-003 Dobra (Szczecińska), Poland; (W.M.); (R.D.)
| | - Andrzej Sikorski
- Department of Urology and Urological Oncology, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 71-899 Szczecin, Poland; (A.S.); (M.S.); (A.G.)
| | - Jacek Gronwald
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
- Read-Gene, Grzepnica, ul. Alabastrowa 8, 72-003 Dobra (Szczecińska), Poland; (W.M.); (R.D.)
| | - Marcin Słojewski
- Department of Urology and Urological Oncology, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 71-899 Szczecin, Poland; (A.S.); (M.S.); (A.G.)
| | - Cezary Cybulski
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
- Read-Gene, Grzepnica, ul. Alabastrowa 8, 72-003 Dobra (Szczecińska), Poland; (W.M.); (R.D.)
| | - Adam Gołąb
- Department of Urology and Urological Oncology, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 71-899 Szczecin, Poland; (A.S.); (M.S.); (A.G.)
| | - Tomasz Huzarski
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
- Read-Gene, Grzepnica, ul. Alabastrowa 8, 72-003 Dobra (Szczecińska), Poland; (W.M.); (R.D.)
- Department of Clinical Genetics and Pathology, University of Zielona Góra, ul. Zyty 28, 65-046 Zielona Góra, Poland
| | - Tadeusz Dębniak
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
| | - Marcin R. Lener
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
| | - Anna Jakubowska
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
| | - Tomasz Kluz
- Department of Gynecology, Gynecology Oncology and Obstetrics, Fryderyk Chopin University Hospital No. 1, ul. Szopena 2, 35-055 Rzeszow, Poland;
- Institute of Medical Sciences, Medical College of Rzeszow University, al. Rejtana 16c, 35-959 Rzeszow, Poland
| | - Marianna Soroka
- Department of Genetics and Genomics, Institute of Biology, University of Szczecin, ul. Felczaka 3c, 71-412 Szczecin, Poland;
| | - Rodney J. Scott
- Priority Research Centre for Cancer Research, Innovation and Translation, Hunter Medical Research Institute, New Lambton, NSW 2305, Australia;
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia
- Division of Molecular Medicine, Pathology North, John Hunter Hospital, New Lambton, NSW 2305, Australia
| | - Jan Lubiński
- Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland; (S.P.); (M.M.); (A.K.); (P.B.); (M.B.); (J.G.); (C.C.); (T.H.); (T.D.); (M.R.L.); (A.J.)
- Read-Gene, Grzepnica, ul. Alabastrowa 8, 72-003 Dobra (Szczecińska), Poland; (W.M.); (R.D.)
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2
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Ude CC, Schmidt SJ, Laurencin S, Shah S, Esdaille J, Kan HM, Holt BD, Arnold AM, Wolf ME, Nair LS, Sydlik SA, Laurencin CT. Hyaluronic acid-British anti-Lewisite as a safer chelation therapy for the treatment of arthroplasty-related metallosis. Proc Natl Acad Sci U S A 2023; 120:e2309156120. [PMID: 37903261 PMCID: PMC10636327 DOI: 10.1073/pnas.2309156120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/17/2023] [Indexed: 11/01/2023] Open
Abstract
Cobalt-containing alloys are useful for orthopedic applications due to their low volumetric wear rates, corrosion resistance, high mechanical strength, hardness, and fatigue resistance. Unfortunately, these prosthetics release significant levels of cobalt ions, which was only discovered after their widespread implantation into patients requiring hip replacements. These cobalt ions can result in local toxic effects-including peri-implant toxicity, aseptic loosening, and pseudotumor-as well as systemic toxic effects-including neurological, cardiovascular, and endocrine disorders. Failing metal-on-metal (MoM) implants usually necessitate painful, risky, and costly revision surgeries. To treat metallosis arising from failing MoM implants, a synovial fluid-mimicking chelator was designed to remove these metal ions. Hyaluronic acid (HA), the major chemical component of synovial fluid, was functionalized with British anti-Lewisite (BAL) to create a chelator (BAL-HA). BAL-HA effectively binds cobalt and rescues in vitro cell vitality (up to 370% of cells exposed to IC50 levels of cobalt) and enhances the rate of clearance of cobalt in vivo (t1/2 from 48 h to 6 h). A metallosis model was also created to investigate our therapy. Results demonstrate that BAL-HA chelator system is biocompatible and capable of capturing significant amounts of cobalt ions from the hip joint within 30 min, with no risk of kidney failure. This chelation therapy has the potential to mitigate cobalt toxicity from failing MoM implants through noninvasive injections into the joint.
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Affiliation(s)
- Chinedu C. Ude
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Stephen J. Schmidt
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Samuel Laurencin
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Shiv Shah
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
- Department of Chemical and Biomolecular Engineering, University of Connecticut, Storrs, CT06269
| | - Jayson Esdaille
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Ho-Man Kan
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Brian D. Holt
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Anne M. Arnold
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Michelle E. Wolf
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Lakshmi S. Nair
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
- Department of Chemical and Biomolecular Engineering, University of Connecticut, Storrs, CT06269
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT06269
- Department of Materials Science and Engineering, University of Connecticut, Storrs, CT06269
- Institute of Materials Science, University of Connecticut, Storrs, CT06269
| | - Stefanie A. Sydlik
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA15213
| | - Cato T. Laurencin
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
- Department of Chemical and Biomolecular Engineering, University of Connecticut, Storrs, CT06269
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT06269
- Department of Materials Science and Engineering, University of Connecticut, Storrs, CT06269
- Institute of Materials Science, University of Connecticut, Storrs, CT06269
- Department of Craniofacial Sciences, School of Dental Medicine, University of Connecticut Health, Farmington, CT06030
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Genchi G, Lauria G, Catalano A, Carocci A, Sinicropi MS. Prevalence of Cobalt in the Environment and Its Role in Biological Processes. BIOLOGY 2023; 12:1335. [PMID: 37887045 PMCID: PMC10604320 DOI: 10.3390/biology12101335] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/08/2023] [Accepted: 10/14/2023] [Indexed: 10/28/2023]
Abstract
Cobalt (Co) is an essential trace element for humans and other animals, but high doses can be harmful to human health. It is present in some foods such as green vegetables, various spices, meat, milk products, seafood, and eggs, and in drinking water. Co is necessary for the metabolism of human beings and animals due to its key role in the formation of vitamin B12, also known as cobalamin, the biological reservoir of Co. In high concentrations, Co may cause some health issues such as vomiting, nausea, diarrhea, bleeding, low blood pressure, heart diseases, thyroid damage, hair loss, bone defects, and the inhibition of some enzyme activities. Conversely, Co deficiency can lead to anorexia, chronic swelling, and detrimental anemia. Co nanoparticles have different and various biomedical applications thanks to their antioxidant, antimicrobial, anticancer, and antidiabetic properties. In addition, Co and cobalt oxide nanoparticles can be used in lithium-ion batteries, as a catalyst, a carrier for targeted drug delivery, a gas sensor, an electronic thin film, and in energy storage. Accumulation of Co in agriculture and humans, due to natural and anthropogenic factors, represents a global problem affecting water quality and human and animal health. Besides the common chelating agents used for Co intoxication, phytoremediation is an interesting environmental technology for cleaning up soil contaminated with Co. The occurrence of Co in the environment is discussed and its involvement in biological processes is underlined. Toxicological aspects related to Co are also examined in this review.
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Affiliation(s)
- Giuseppe Genchi
- Dipartimento di Farmacia e Scienze della Salute e della Nutrizione, Università della Calabria, Arcavacata di Rende, 87036 Cosenza, Italy; (G.G.); (G.L.); (M.S.S.)
| | - Graziantonio Lauria
- Dipartimento di Farmacia e Scienze della Salute e della Nutrizione, Università della Calabria, Arcavacata di Rende, 87036 Cosenza, Italy; (G.G.); (G.L.); (M.S.S.)
| | - Alessia Catalano
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari “A. Moro”, 70125 Bari, Italy;
| | - Alessia Carocci
- Dipartimento di Farmacia-Scienze del Farmaco, Università degli Studi di Bari “A. Moro”, 70125 Bari, Italy;
| | - Maria Stefania Sinicropi
- Dipartimento di Farmacia e Scienze della Salute e della Nutrizione, Università della Calabria, Arcavacata di Rende, 87036 Cosenza, Italy; (G.G.); (G.L.); (M.S.S.)
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Moravcová M, Lomozová Z, Kučera R, Mladěnka P. 3-Hydroxyflavone is a mildly active and safe cobalt chelator while cobalt markedly enhances baicalein toxicity toward erythrocytes. RSC Adv 2023; 13:29242-29251. [PMID: 37809024 PMCID: PMC10551802 DOI: 10.1039/d3ra02735j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/21/2023] [Indexed: 10/10/2023] Open
Abstract
Cobalt intoxication can occur after its release from metal-based prostheses, which is generally clinically severe. Therefore, there is a need for the development of a cobalt chelator since there are currently no approved drugs for cobalt intoxication. As flavonoids are known for their metal chelating properties and safety, the screening of cobalt chelating properties was performed in a total of 23 flavonoids by our recently developed new spectrophotometric assay. Further assessment of positive or negative consequences of cobalt chelation was performed both in vitro and ex vivo. Six and thirteen flavonoids significantly chelated cobalt ions at pH 7.5 and 6.8, respectively. Baicalein demonstrated a significant activity even at pH 5.5; however, none of the flavonoids showed chelation at pH 4.5. In general, baicalein and 3-hydroxyflavone were the most active. They also mildly decreased the cobalt-triggered Fenton reaction, but baicalein toxicity toward red blood cells was strongly increased by the addition of cobalt. Quercetin, tested as an example of flavonoid unable to chelate cobalt ions significantly, stimulated both the cobalt-based Fenton reaction and the lysis of erythrocytes in the presence of cobalt. Therefore, 3-hydroxyflavone can serve as a potential template for the development of novel cobalt chelators.
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Affiliation(s)
- Monika Moravcová
- The Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University Akademika Heyrovského 1203 50005 Hradec Králové Czech Republic +420-495-067-295
| | - Zuzana Lomozová
- The Department of Pharmacognosy and Pharmaceutical Botany, Faculty of Pharmacy in Hradec Králové, Charles University Akademika Heyrovského 1203 50005 Hradec Králové Czech Republic
| | - Radim Kučera
- The Department of Pharmaceutical Chemistry and Pharmaceutical Analysis, Faculty of Pharmacy in Hradec Králové, Charles University Akademika Heyrovského 1203 50005 Hradec Králové Czech Republic
| | - Přemysl Mladěnka
- The Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University Akademika Heyrovského 1203 50005 Hradec Králové Czech Republic +420-495-067-295
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Domínguez-García A, Jiménez-Meseguer M, Salas-Pérez JM, García-Martínez S, Hidalgo-Correas F, García-Díaz B. Cobalt poisoning secondary to hip prosthesis: A case report. FARMACIA HOSPITALARIA 2023; 47:139-140. [PMID: 37117087 DOI: 10.1016/j.farma.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 04/30/2023] Open
Affiliation(s)
| | | | | | | | | | - Benito García-Díaz
- Servicio de Farmacia, Hospital Universitario Severo Ochoa, Leganés, España
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Domínguez García A, Jiménez Meseguer M, Salas Pérez JM, García Martínez S, Hidalgo Correas F, García Díaz B. [Translated article] Cobalt poisoning secondary to hip prosthesis: A case report. FARMACIA HOSPITALARIA 2023; 47:T139-T140. [PMID: 37246121 DOI: 10.1016/j.farma.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 05/30/2023] Open
Affiliation(s)
| | | | | | | | | | - Benito García Díaz
- Servicio de Farmacia Hospital Universitario Severo Ochoa, Leganés, Spain
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Intracranial hypertension associated with arthroprosthetic cobaltism? Am J Ophthalmol Case Rep 2022; 25:101255. [PMID: 35059530 PMCID: PMC8760431 DOI: 10.1016/j.ajoc.2022.101255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 12/30/2021] [Accepted: 01/02/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose The purpose of this case report was to detail a unique patient with proven systemic cobaltism from metal-on-metal prosthetic hip articulation who then presented with clinical and radiographic signs of increased intracranial pressure. Observations A 59-year-old man with a past medical history of degenerative joint disease of the hip that status post total hip arthroplasty with cobalt-chromium implant presented with clinical and radiographic signs of increased intracranial hypertension. He underwent a revision arthroplasty with local debridement and removal of the cobalt-chromium implant and his serum cobalt level was elevated at 0.9 microg/L (normal range 0.1–0.4microg/L). One year after removal of the implant, the patient was asymptomatic and stable on acetazolamide. Conclusions To our knowledge, this is the first such report in the English literature to associate increased intracranial hypertension with systemic cobaltism, and publication of this case report would make clinicians aware of the potential neurologic and neuro-ophthalmic presentation of metal-on-metal orthopedic prosthetics.
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Yan BW, Bini SA. Neurologic Dysfunction Associated With Mechanically Assisted Crevice Corrosion and Elevated Cobalt Ion Levels After Total Hip Arthroplasty. Arthroplast Today 2021; 11:217-221. [PMID: 34646925 PMCID: PMC8501461 DOI: 10.1016/j.artd.2021.09.002] [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] [Received: 07/07/2021] [Revised: 08/30/2021] [Accepted: 09/02/2021] [Indexed: 10/29/2022] Open
Abstract
Adverse local tissue reactions secondary to mechanically assisted crevice corrosion (MACC) at the trunnion is a complication of total hip arthroplasty known to cause local soft-tissue damage. However, what is not as well appreciated is that MACC in metal-on-polyethylene (MOP) articulations can lead to cobalt ion serum elevations with associated neurological dysfunction just as in metal-on-metal articulations. We report a compelling case for the association of neurologic dysfunction tied to metal ion elevations secondary to MACC at two distinct MOP tapers in a 58-year-old intensive care unit nurse with two hips implanted 3 years apart. This report further raises awareness about the potential of MACC-generated elevated ion levels to produce neurological symptoms that might otherwise be overlooked in patients with MOP articulations.
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Affiliation(s)
- Brandon W Yan
- School of Medicine, University of California San Francisco (UCSF), San Francisco, CA, USA
| | - Stefano A Bini
- Department of Orthopaedic Surgery, UCSF School of Medicine, San Francisco, CA, USA
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9
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Liu Y, Zhu W, Ni D, Zhou Z, Gu JH, Zhang W, Sun H, Liu F. Alpha lipoic acid antagonizes cytotoxicity of cobalt nanoparticles by inhibiting ferroptosis-like cell death. J Nanobiotechnology 2020; 18:141. [PMID: 33008409 PMCID: PMC7532644 DOI: 10.1186/s12951-020-00700-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/24/2020] [Indexed: 12/20/2022] Open
Abstract
As a main element in the hard metal industry, cobalt is one of the major components of human metal implants. Cobalt-containing implants, especially joint prostheses used for artificial joint replacement, can be corroded due to the complex physiological environment in vivo, producing a large number of nanoscale cobalt particles (Cobalt Nanoparticles, CoNPs). These CoNPs can be first accumulated around the implant to cause adverse local reactions and then enter into the blood vessels followed by reaching the liver, heart, brain, kidney, and other organs through systematic circulation, which leads to multi-system toxicity symptoms. To ensure the long-term existence of cobalt-containing implants in the body, it is urgently required to find out a safe and effective detoxification drug. Herein, we have demonstrated that CoNPs could induce the ferroptosis-like cell death through the enhancement of intracellular reactive oxygen species (ROS) level, cytoplasmic Fe2+ level, lipid peroxidation, and consumption of reduced glutathione (GSH) as well as inhibition of glutathione peroxidase 4 (GPX4) activity. Importantly, α-lipoic acid (ALA), a natural antioxidant with the capability to scavenge free radicals and chelate toxic metals, was found to efficiently alleviate the adverse effects of CoNPs. The present study illustrates a new mechanism of CoNPs mediated by ferroptosis-like cytotoxicity and discloses an effective method for the detoxification of CoNPs by employing the natural antioxidant of ALA, providing a basis for further in vivo detoxification study.![]()
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Affiliation(s)
- Yake Liu
- Department of Orthopaedics, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, Jiangsu, China.,Orthopaedic Laboratory, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Wenfeng Zhu
- Department of Orthopaedics, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, Jiangsu, China.,Department of Orthopaedics, The Sixth Affiliated Hospital of Nantong University, Yancheng, Jiangsu Province, China
| | - Dalong Ni
- Department of Radiology, University of Wisconsin-Madison, 11111 Highland Avenue, Madison, WI, 53705, USA
| | - Zihua Zhou
- Orthopaedic Laboratory, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Jin-Hua Gu
- Department of Clinical Pharmacy, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Weinan Zhang
- Department of Orthopaedics, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, Jiangsu, China.,Orthopaedic Laboratory, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Huanjian Sun
- Department of Orthopaedics, The Sixth Affiliated Hospital of Nantong University, Yancheng, Jiangsu Province, China
| | - Fan Liu
- Department of Orthopaedics, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, Jiangsu, China.
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Schoon J, Hesse B, Rakow A, Ort MJ, Lagrange A, Jacobi D, Winter A, Huesker K, Reinke S, Cotte M, Tucoulou R, Marx U, Perka C, Duda GN, Geissler S. Metal-Specific Biomaterial Accumulation in Human Peri-Implant Bone and Bone Marrow. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2020; 7:2000412. [PMID: 33101844 PMCID: PMC7578891 DOI: 10.1002/advs.202000412] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/09/2020] [Indexed: 05/13/2023]
Abstract
Metallic implants are frequently used in medicine to support and replace degenerated tissues. Implant loosening due to particle exposure remains a major cause for revision arthroplasty. The exact role of metal debris in sterile peri-implant inflammation is controversial, as it remains unclear whether and how metals chemically alter and potentially accumulate behind an insulating peri-implant membrane, in the adjacent bone and bone marrow (BM). An intensively focused and bright synchrotron X-ray beam allows for spatially resolving the multi-elemental composition of peri-implant tissues from patients undergoing revision surgery. In peri-implant BM, particulate cobalt (Co) is exclusively co-localized with chromium (Cr), non-particulate Cr accumulates in the BM matrix. Particles consisting of Co and Cr contain less Co than bulk alloy, which indicates a pronounced dissolution capacity. Particulate titanium (Ti) is abundant in the BM and analyzed Ti nanoparticles predominantly consist of titanium dioxide in the anatase crystal phase. Co and Cr but not Ti integrate into peri-implant bone trabeculae. The characteristic of Cr to accumulate in the intertrabecular matrix and trabecular bone is reproducible in a human 3D in vitro model. This study illustrates the importance of updating the view on long-term consequences of biomaterial usage and reveals toxicokinetics within highly sensitive organs.
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Affiliation(s)
- Janosch Schoon
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Berlin‐Brandenburg School for Regenerative TherapiesCharité – Universitätsmedizin BerlinBerlin13353Germany
| | - Bernhard Hesse
- Xploraytion GmbHBerlin10625Germany
- European Synchrotron Radiation FacilityGrenoble38000France
| | - Anastasia Rakow
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Center for Musculoskeletal SurgeryCharité – Universitätsmedizin BerlinBerlin10117Germany
| | - Melanie J. Ort
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Berlin‐Brandenburg School for Regenerative TherapiesCharité – Universitätsmedizin BerlinBerlin13353Germany
| | - Adrien Lagrange
- Xploraytion GmbHBerlin10625Germany
- Department of Materials Science and EngineeringInstitute of Materials Science and TechnologiesTechnische Universität BerlinBerlin10623Germany
| | - Dorit Jacobi
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
| | | | - Katrin Huesker
- Endocrinology and Immunology DepartmentInstitute for Medical DiagnosticsBerlin12247Germany
| | - Simon Reinke
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
| | - Marine Cotte
- European Synchrotron Radiation FacilityGrenoble38000France
- CNRSLaboratoire d'archéologie moléculaire et structuraleLAMSSorbonne UniversitéParis75005France
| | - Remi Tucoulou
- European Synchrotron Radiation FacilityGrenoble38000France
| | | | - Carsten Perka
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Berlin‐Brandenburg School for Regenerative TherapiesCharité – Universitätsmedizin BerlinBerlin13353Germany
- Center for Musculoskeletal SurgeryCharité – Universitätsmedizin BerlinBerlin10117Germany
| | - Georg N. Duda
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Berlin‐Brandenburg School for Regenerative TherapiesCharité – Universitätsmedizin BerlinBerlin13353Germany
| | - Sven Geissler
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Berlin‐Brandenburg School for Regenerative TherapiesCharité – Universitätsmedizin BerlinBerlin13353Germany
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11
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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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12
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A Systematic Review of Systemic Cobaltism After Wear or Corrosion of Chrome-Cobalt Hip Implants. J Patient Saf 2020; 15:97-104. [PMID: 26076080 PMCID: PMC6553976 DOI: 10.1097/pts.0000000000000220] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives We sought to synthesize data on systemic arthroprosthetic cobaltism, a recently described syndrome that results from wear or corrosion of chrome-cobalt hip components. Methods We conducted a systematic literature review to identify all reported cases of systemic arthroprosthetic cobaltism. To assess the epidemiologic link between blood cobalt levels (B[Co]), we developed a symptom scoring tool that evaluated 9 different symptom categories and a category of medical utilization. Results We identified 25 patients reported between 2001 and 2014 with a substantial increase in case reports over the past 3 years. Symptoms were diverse and involved the hip (84%), cardiovascular system (60%), audiovestibular system (52%), peripheral motor-sensory system (48%), thyroid (48%), psychological functioning (32%), visual system (32%), and the hematological, oncological, or immune system (20%). The mean latency from implantation to presentation or revision was 41 months (range, 9–99 months). The mean B[Co] was 324 μg/L and 4 patients had levels less than 20 μg/L. The B[Co] but not blood chromium level was highly associated with a quantitative measure of overall symptom severity (r2, 0.81; P < 0.001). Mean B[Co] and symptom scores were substantially higher in patients with revisions of failed ceramic-on-ceramic prostheses than those with primary metal-on-metal prostheses. Conclusions Systemic arthroprosthetic cobaltism is an increasingly recognized complication of wear or corrosion of chrome-cobalt hip implants, may involve a large number of organ systems, and may occur with relatively low B[Co]. There is an urgent need to better define the overall scope of the problem and to develop screening and management strategies.
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D'Ambrosi R, Ursino N. N-Acetyl-Cysteine Reduces Blood Chromium and Cobalt Levels in Metal-on-Metal Hip Arthroplasty. Arthroplast Today 2020; 6:149-152. [PMID: 32346587 PMCID: PMC7183002 DOI: 10.1016/j.artd.2020.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/11/2020] [Accepted: 03/14/2020] [Indexed: 11/27/2022] Open
Abstract
The most common reasons for revision of metal-on-metal hip arthroplasty are aseptic loosening and metal reaction. Failure of a metal-on-metal implant due to the aggressive destruction of periprosthetic tissues may require extensive reconstruction procedures. The aim of this case report is to describe the treatment in an asymptomatic patient with high levels of chromium and cobalt, using chelation therapy. The rational use of N-acetyl-cysteine (NAC) involves thiol groups to chelate sites for metals. More than 10 years after the metal-on-metal hip arthroplasty, the patient did not have to undergo revision surgery; the levels of the ions in the blood were considerably lowered (chromium from 4.51 mcg/L to 1.85 mcg/L; cobalt from 7.78 UG/L to 0.8 UG/L) after using NAC without adverse effects.
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14
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In vitro assessment of cobalt oxide particle dissolution in simulated lung fluids for identification of new decorporating agents. Toxicol In Vitro 2020; 66:104863. [PMID: 32304792 DOI: 10.1016/j.tiv.2020.104863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 11/23/2022]
Abstract
Inhalation of 60Co3O4 particles may occur at the work place in nuclear industry. Their low solubility may result in chronic lung exposure to γ rays. Our strategy for an improved therapeutic approach is to enhance particle dissolution to facilitate cobalt excretion, as the dissolved fraction is rapidly eliminated, mainly in urine. In vitro dissolution of Co3O4 particles was assessed with two complementary assays in lung fluid surrogates to mimic a pulmonary contamination scenario. Twenty-one molecules and eleven combinations were selected through an extensive search in the literature, based on dissolution studies of other metal oxides (Fe, Mn, Cu) and tested for dissolution enhancement of cobalt particles after 1-28 days of incubation. DTPA, the recommended treatment following cobalt contamination did not enhance 60Co3O4 particles dissolution when used alone. However, by combining molecules with different properties, such as redox potential and chelating ability, we greatly improved the efficacy of each drug used alone, leading for the highest efficacy, to a 2.7 fold increased dissolution as compared to controls. These results suggest that destabilization of the particle surface is an important initiating event for a good efficacy of chelating drugs, and open new perspectives for the identification of new therapeutic strategies.
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15
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Maurer-Ertl W, Fellner A, Reinbacher P, Maier M, Leithner A, Friesenbichler J. Blood Management in Revision Total Hip Arthroplasty for Metal-on-Metal Devices: The Efficiency of an Intraoperative Cell Salvage System. Indian J Orthop 2020; 54:164-167. [PMID: 32257033 PMCID: PMC7096336 DOI: 10.1007/s43465-019-00026-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 07/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this series was to investigate the efficiency of an intraoperative cell salvage system (ICS) removing metal ions during revision of metal-on-metal (MoM) devices to proof the possibility of re-transfusion of the collected blood. MATERIALS AND METHODS Between 2014 and 2018, five consecutive patients underwent revision surgery of their MoM total hip arthroplasty due to wear of the polyethylene-metal sandwich inlay or local massive metallosis with aseptic loosing of the cup. Aspiration of joint fluid of all hip prostheses was done and blood was taken to measure the metal ion concentrations, preoperatively. Perioperatively, blood was collected using an ICS before and after filtration and analyzed for Co and Cr concentrations. At that time, there was no re-transfusion of the collected and filtrated blood due to unknown metal ion concentrations. RESULTS The mean preoperative serum Co and Cr concentrations in the blood were 31.28 μg/L (range 0.22-77.47) and 17.33 μg/L (range 0.59-51.31), whereas the mean local concentrations in the aspiration fluid were 728-fold and 822-fold higher. The Co and Cr concentrations measured in the collected blood before filtration were 70.61 μg/L (range 9.40-173.00) and 337.21 μg/L (range 8.76-1383.0) and decreased markedly to average concentrations of 15.49 μg/L and 41.88 μg/L, respectively. These differences were statistically not significant (Co: p = 0.117, Cr: p = 0.175), although the mean reduction rates were 78% and 88% for Co and Cr, respectively. CONCLUSION The current series showed that in case of revision of MoM hip devices, metal ions are still contained in the collected blood following filtration using a modern high-level ICS. Therefore, we would only recommend blood re-transfusion in case of low preoperative Co and Cr concentrations and sufficient renal function to warrant patients' safety.
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Affiliation(s)
- Werner Maurer-Ertl
- grid.11598.340000 0000 8988 2476Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Andreas Fellner
- grid.11598.340000 0000 8988 2476Department of Anaesthesiology, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Patrick Reinbacher
- grid.11598.340000 0000 8988 2476Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Michael Maier
- grid.11598.340000 0000 8988 2476Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Andreas Leithner
- grid.11598.340000 0000 8988 2476Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Joerg Friesenbichler
- grid.11598.340000 0000 8988 2476Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
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16
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Abstract
Cobalt-induced cardiomyopathy is a well-known but uncommon disease, and the physician must maintain a high index of suspicion in order to make a timely diagnosis. We report two patients with cobalt-induced cardiomyopathy. Both patients developed progressively worsening symptoms of cobalt toxicity following revision of a fractured ceramic-on-ceramic total hip replacement to a metal-on-polyethylene bearing. In both patients, echocardiography showed LV hypertrophy, biventricular systolic dysfunction, and a large amount of pericardial effusion. Due to decompensated heart failure, both patients were initially considered candidates for heart transplantation. One patient was diagnosed with cobalt-induced cardiomyopathy before transplantation. He received cobalt chelation therapy and revision surgery, which led to complete recovery of heart function. In the other patient, the diagnosis was not made until the time of heart transplantation. The gross examination of the explanted heart revealed typical features of cobalt cardiotoxicity, which was then diagnosed as cobalt-induced cardiomyopathy. These cases emphasise the importance of early diagnosis and prompt treatment of cobalt intoxication.
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17
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Kovochich M, Finley BL, Novick R, Monnot AD, Donovan E, Unice KM, Fung ES, Fung D, Paustenbach DJ. Understanding outcomes and toxicological aspects of second generation metal-on-metal hip implants: a state-of-the-art review. Crit Rev Toxicol 2019; 48:853-901. [DOI: 10.1080/10408444.2018.1563048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Sangaletti R, Spreafico A, Barbieri F, Ferrari R, Castelli CC. Metal ion trend in patients with metal-on-metal total hip arthroplasty: a 10-year prospective study. Hip Int 2018; 28:43-47. [PMID: 30755113 DOI: 10.1177/1120700018812991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION: There have been reported adverse reactions in patients with large head metal-on-metal hip arthroplasty, therefore metal particle debris are a cause for concern. The aim of this study was to evaluate the release trend of metal ions and the correlated variables. METHODS: 54 patients were prospectively enrolled into the study from 2004 to 2006. All patients had 36-mm metal head, Pinnacle acetabular component, Summit stem and Ultamet CoCr alloy liner (Depuy Inc.), and underwent clinical and radiological management. The haematic concentration of Cr-Co at 0, 6, 12, 24, 60 and 120 months after the implantation was analysed in a sub-cohort of 34 patients. RESULTS: 10-year revision rate for each case was 8.9%. The average concentration of Co at 120 months was 3.12 μg/L (median 2.20) with 53% values >2 μg/L and 1 >7 μg/L. After 6 months the median levels of Cr and Co were higher than time 0 ( p < 0.0001); no significant differences were found between 6 and 24 months; while Co had significant increase between 60 and 120 months ( p = 0.002). Overweight, University of California at Los Angeles (UCLA) >9 and <50 years old patients have significantly higher circulating metal ions. DISCUSSION: This is 1 of the few prospective studies on the argument. The revision rate is conforming to records. Our data shows ionic concentration is not predictive of revision or adverse reaction to metals. We described a 3-phase trend for Co probably due to the loss of integrity of the surfaces.
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Affiliation(s)
- Rudy Sangaletti
- Department of Orthopaedics and Traumatology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Andrea Spreafico
- Department of Orthopaedics and Traumatology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Flavio Barbieri
- Department of Orthopaedics and Traumatology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Roberto Ferrari
- Department of Orthopaedics and Traumatology, ASST Papa Giovanni XXIII, Bergamo, Italy
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Pilz YL, Bass SJ, Sherman J. A Review of Mitochondrial Optic Neuropathies: From Inherited to Acquired Forms. JOURNAL OF OPTOMETRY 2017; 10:205-214. [PMID: 28040497 PMCID: PMC5595256 DOI: 10.1016/j.optom.2016.09.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/02/2016] [Accepted: 09/22/2016] [Indexed: 05/28/2023]
Abstract
In recent years, the term mitochondrial optic neuropathy (MON) has increasingly been used within the literature to describe a group of optic neuropathies that exhibit mitochondrial dysfunction in retinal ganglion cells (RGCs). Interestingly, MONs include genetic aetiologies, such as Leber hereditary optic neuropathy (LHON) and dominant optic atrophy (DOA), as well as acquired aetiologies resulting from drugs, nutritional deficiencies, and mixed aetiologies. Regardless of an inherited or acquired cause, patients exhibit the same clinical manifestations with selective loss of the RGCs due to mitochondrial dysfunction. Various novel therapies are being explored to reverse or limit damage to the RGCs. Here we review the pathophysiology, clinical manifestations, differential diagnosis, current treatment, and promising therapeutic targets of MON.
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MESH Headings
- DNA, Mitochondrial
- Diagnosis, Differential
- Humans
- Mitochondrial Diseases/diagnosis
- Mitochondrial Diseases/genetics
- Mitochondrial Diseases/physiopathology
- Mitochondrial Diseases/therapy
- Optic Atrophy, Autosomal Dominant/diagnosis
- Optic Atrophy, Autosomal Dominant/genetics
- Optic Atrophy, Autosomal Dominant/physiopathology
- Optic Atrophy, Autosomal Dominant/therapy
- Optic Atrophy, Hereditary, Leber/diagnosis
- Optic Atrophy, Hereditary, Leber/genetics
- Optic Atrophy, Hereditary, Leber/physiopathology
- Optic Atrophy, Hereditary, Leber/therapy
- Optic Nerve Diseases/diagnosis
- Optic Nerve Diseases/genetics
- Optic Nerve Diseases/physiopathology
- Optic Nerve Diseases/therapy
- Retinal Ganglion Cells/pathology
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Affiliation(s)
- Yasmine L Pilz
- State University New York, College of Optometry, New York, USA.
| | - Sherry J Bass
- State University New York, College of Optometry, New York, USA
| | - Jerome Sherman
- State University New York, College of Optometry, New York, USA
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20
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Abstract
BACKGROUND Ocular cobalt toxicity is a rare phenomenon reported with increased frequency due to the rise of cobalt-chromium metal hip implants. We report the case of a 66-year-old previously healthy man who developed decreased vision due to cobalt-chromium toxicity from a metal-on-metal hip arthroplasty. Our objective was to determine whether the origin of his visual loss was due to toxicity of the optic nerve, of the retina, or of both. METHODS Ocular examination, 10-2 SITA-Standard Humphrey Visual Field (VF), standard full-field electroretinogram (ERG) as indicated by the International Society for Clinical Electrophysiology of Vision (ISCEV), multifocal electroretinogram (mfERG), multifocal visual evoked potentials (mfVEP), and optical coherence tomography (OCT) were conducted. RESULTS Ocular examination revealed decreased visual acuity, poor color vision, normal funduscopy, and cecocentral scotomas on VF testing. Because his right eye was amblyopic since childhood, test results from only the left eye are shown. Electrophysiology studies revealed an ISCEV standard full-field ERG with photopic and scotopic responses within normal limits, mfERG with amplitudes and latencies within normal limits, and mfVEP with latencies within normal limits, but with decreased central amplitudes. Peripapillary and macular OCT showed retinal nerve fiber layer and retinal ganglion cell-inner plexiform layer thickness within normal limits. CONCLUSION Because decreased color vision and cecocentral scotoma on 10-2 VF are most consistent with toxic optic neuropathy, and decreased central amplitudes on mfVEP are suggestive of neural dysfunction, we hypothesize that our patient presented with an early stage of optic nerve toxicity that was not yet apparent as a structural abnormality on OCT.
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21
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Leyssens L, Vinck B, Van Der Straeten C, Wuyts F, Maes L. Cobalt toxicity in humans-A review of the potential sources and systemic health effects. Toxicology 2017; 387:43-56. [PMID: 28572025 DOI: 10.1016/j.tox.2017.05.015] [Citation(s) in RCA: 397] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/17/2017] [Accepted: 05/24/2017] [Indexed: 12/21/2022]
Abstract
Cobalt (Co) and its compounds are widely distributed in nature and are part of numerous anthropogenic activities. Although cobalt has a biologically necessary role as metal constituent of vitamin B12, excessive exposure has been shown to induce various adverse health effects. This review provides an extended overview of the possible Co sources and related intake routes, the detection and quantification methods for Co intake and the interpretation thereof, and the reported health effects. The Co sources were allocated to four exposure settings: occupational, environmental, dietary and medical exposure. Oral intake of Co supplements and internal exposure through metal-on-metal (MoM) hip implants deliver the highest systemic Co concentrations. The systemic health effects are characterized by a complex clinical syndrome, mainly including neurological (e.g. hearing and visual impairment), cardiovascular and endocrine deficits. Recently, a biokinetic model has been proposed to characterize the dose-response relationship and effects of chronic exposure. According to the model, health effects are unlikely to occur at blood Co concentrations under 300μg/l (100μg/l respecting a safety factor of 3) in healthy individuals, hematological and endocrine dysfunctions are the primary health endpoints, and chronic exposure to acceptable doses is not expected to pose considerable health hazards. However, toxic reactions at lower doses have been described in several cases of malfunctioning MoM hip implants, which may be explained by certain underlying pathologies that increase the individual susceptibility for Co-induced systemic toxicity. This may be associated with a decrease in Co bound to serum proteins and an increase in free ionic Co2+. As the latter is believed to be the primary toxic form, monitoring of the free fraction of Co2+ might be advisable for future risk assessment. Furthermore, future research should focus on longitudinal studies in the clinical setting of MoM hip implant patients to further elucidate the dose-response discrepancies.
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Affiliation(s)
- Laura Leyssens
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Bart Vinck
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium; Faculty of Humanities, University of Pretoria (South Africa), Department of Speech-Language Pathology and Audiology, Aula Theatre,University Road, Pretoria, 0001, South Africa.
| | - Catherine Van Der Straeten
- Faculty of Medicine, Imperial College London, Department of Surgery & Cancer, Musculoskeletal Sciences and Technology, Imperial College London, Charing Cross Campus,7L21 Lab Block, London SW7 2AZ, UK; Faculty of Medicine and Health Sciences, University of Ghent (Belgium), De Pintelaan 185, 9000 Ghent, Belgium.
| | - Floris Wuyts
- Antwerp University Research center for Equilibrium and Aerospace (AUREA), Department of Otorhinolaryngology, University Hospital Antwerp, Campus Groenenborger, Groenenborgerlaan 171, 2020 Antwerp, Belgium; Department of Biomedical Physics, University of Antwerp (Belgium), Campus Groenenborger, Groenenborgerlaan 171, 2020 Antwerp, Belgium.
| | - Leen Maes
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium; Clinical audiology department, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium.
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Pelayo-de Tomás J, Novoa-Parra C, Gómez-Barbero P. Cobalt toxicity after revision total hip replacement due to fracture of a ceramic head. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017. [DOI: 10.1016/j.recote.2017.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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23
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Pelayo-de Tomás JM, Novoa-Parra C, Gómez-Barbero P. Cobalt toxicity after revision total hip replacement due to fracture of a ceramic head. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 61:203-207. [PMID: 28131541 DOI: 10.1016/j.recot.2016.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 11/06/2016] [Accepted: 11/10/2016] [Indexed: 11/27/2022] Open
Abstract
Symptomatic cobalt toxicity from a failed total hip replacement is a rare, but devastating complication. Potential clinical findings include cardiomyopathy, hypothyroidism, skin rash, visual and hearing impairment, polycythaemia, weakness, fatigue, cognitive impairment, and neuropathy. The case is presented of a 74year-old man in whom, after a ceramic-ceramic replacement and two episodes of prosthetic dislocation, it was decided to replace it with a polyethylene-metal total hip arthroplasty (THA). At 6months after the revision he developed symptoms of cobalt toxicity, confirmed by analytical determination (serum cobalt level=651.2μg/L). After removal of the prosthesis, the levels of chromium and cobalt in blood and urine returned to normal, with the patient currently being asymptomatic. It is recommended to use a new ceramic on ceramic bearing at revision, in order to minimise the risk of wear-related cobalt toxicity following breakage of ceramic components.
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Affiliation(s)
- J M Pelayo-de Tomás
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Dr. Peset, Valencia, España
| | - C Novoa-Parra
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Dr. Peset, Valencia, España.
| | - P Gómez-Barbero
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Dr. Peset, Valencia, España
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Grant ML, Karp JK, Palladino M, Le N, Hall N, Herman JH. Does therapeutic plasma exchange have a role in the treatment of prosthetic hip–associated cobalt toxicity? A case report and literature review. Transfusion 2016; 56:2368-73. [DOI: 10.1111/trf.13720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/04/2016] [Accepted: 05/23/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Michelle L. Grant
- Department of Pathology, Anatomy, and Cell BiologyThomas Jefferson University HospitalPhiladelphia Pennsylvania
| | - Julie K. Karp
- Department of Pathology, Anatomy, and Cell BiologyThomas Jefferson University HospitalPhiladelphia Pennsylvania
| | - Michele Palladino
- Department of Pathology, Anatomy, and Cell BiologyThomas Jefferson University HospitalPhiladelphia Pennsylvania
| | - Nguyet Le
- Department of Pathology, Anatomy, and Cell BiologyThomas Jefferson University HospitalPhiladelphia Pennsylvania
| | - Nancy Hall
- Department of Pathology, Anatomy, and Cell BiologyThomas Jefferson University HospitalPhiladelphia Pennsylvania
| | - Jay H. Herman
- Department of Pathology, Anatomy, and Cell BiologyThomas Jefferson University HospitalPhiladelphia Pennsylvania
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Abstract
Hip resurfacing arthroplasty (HRA) presents several advantages over conventional total hip arthroplasty (THA), including conservation and preservation of bone, reduced risk of dislocation, easy replication of hip biomechanics and easy revision if needed. It is a particularly appealing procedure for young patients. HRA has been performed for over 40 years following the same technological advances as THA. The bearing material used by most designs is metal-on-metal (MoM), which has the best compromise between strength and wear properties. However, MoM HRA has a specific set of possible complications. Aseptic femoral failures were initially the most prevalent cause for revision but progress in patient selection and surgical technique seem to have resolved this problem. Wear-related failures (high metal ion levels and adverse local tissue reactions) are now the main concern, and are essentially associated with poor acetabular component design and orientation, to which MoM is more sensitive than other bearing materials. The concept of functional coverage is key to understanding how MoM bearings are affected by edge wear. Only a 3-D assessment of cup position (e.g., the contact patch to rim distance) provides the necessary information to determine the role of cup positioning in relationship with abnormal bearing wear.The concept of hip resurfacing is more valid today than ever as the age of the patients in need of hip arthroplasty keeps getting lower. The recent publication of several excellent long-term survivorship results suggests that selection of a well-designed resurfacing system and accuracy in the placement of the cup can achieve long-term durability.
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Beraudi A, Bianconi E, Catalani S, Canaider S, De Pasquale D, Apostoli P, Bordini B, Stea S, Toni A, Facchin F. In vivo response of heme-oxygenase-1 to metal ions released from metal-on-metal hip prostheses. Mol Med Rep 2016; 14:474-80. [PMID: 27176599 DOI: 10.3892/mmr.2016.5245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 01/20/2016] [Indexed: 11/06/2022] Open
Abstract
Metal ion release and accumulation is considered to be a factor responsible for the high failure rates of metal-on-metal (MoM) hip implants. Numerous studies have associated the presence of these ions, besides other factors, including a hypoxia‑like response and changes in pH due to metal corrosion leading to the induction of the oxidative stress response. The aim of the present study was to verify whether, in patients with a MoM hip prosthesis, mRNA and protein expression of HMOX‑1 was modulated by the presence of metal ions and whether patients without prostheses exhibit a different expression pattern of this enzyme. The study was conducted on 22 matched pairs of patients with and without prostheses, for a total of 44 samples. Ion dosage was determined using inductively coupled plasma mass spectrometry equipped with dynamic cell reaction. HMOX‑1 gene expression was quantified by reverse transcription-quantitative polymerase chain reaction and HMOX‑1 protein expression was analyzed using an enzyme-linked immunosorbent assay. The results demonstrated that although there were significant differences in the metallic ion concentrations amongst the two groups of patients, there was no correlation between circulating levels of cobalt (Co) and chromium (Cr), and HMOX‑1 gene and protein expression. Additionally, there was no significant difference in the protein expression levels of HMOX‑1 between the two groups. In conclusion, it was demonstrated that circulating Co and Cr ions released by articular prosthetics do not induce an increase in HMOX‑1 mRNA and protein expression at least 3.5 years after the implant insertion. The present study suggests that involvement of HMOX‑1 may be excluded from future studies and suggests that other antioxidant enzymes, including superoxide dismutase, glutathione peroxidase and reductase should be investigated.
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Affiliation(s)
- Alina Beraudi
- Medical Technology Laboratory, Rizzoli RIT Department ‑ Research, Innovation and Technology, Rizzoli Orthopaedic Institute, I‑40136 Bologna, Italy
| | - Eva Bianconi
- Department of Experimental, Diagnostic and Specialty Medicine, (DIMES), Unit of Histology, Embryology and Applied Biology, University of Bologna, I‑40136 Bologna, Italy
| | - Simona Catalani
- Unit of Occupational Health and Industrial Hygiene, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, I‑25100 Brescia, Italy
| | - Silvia Canaider
- Department of Experimental, Diagnostic and Specialty Medicine, (DIMES), Unit of Histology, Embryology and Applied Biology, University of Bologna, I‑40136 Bologna, Italy
| | - Dalila De Pasquale
- Medical Technology Laboratory, Rizzoli RIT Department ‑ Research, Innovation and Technology, Rizzoli Orthopaedic Institute, I‑40136 Bologna, Italy
| | - Pietro Apostoli
- Unit of Occupational Health and Industrial Hygiene, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, I‑25100 Brescia, Italy
| | - Barbara Bordini
- Medical Technology Laboratory, Rizzoli RIT Department ‑ Research, Innovation and Technology, Rizzoli Orthopaedic Institute, I‑40136 Bologna, Italy
| | - Susanna Stea
- Medical Technology Laboratory, Rizzoli RIT Department ‑ Research, Innovation and Technology, Rizzoli Orthopaedic Institute, I‑40136 Bologna, Italy
| | - Aldo Toni
- Medical Technology Laboratory, Rizzoli RIT Department ‑ Research, Innovation and Technology, Rizzoli Orthopaedic Institute, I‑40136 Bologna, Italy
| | - Federica Facchin
- Department of Experimental, Diagnostic and Specialty Medicine, (DIMES), Unit of Histology, Embryology and Applied Biology, University of Bologna, I‑40136 Bologna, Italy
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Czekaj J, Ehlinger M, Rahme M, Bonnomet F. Metallosis and cobalt - chrome intoxication after hip resurfacing arthroplasty. J Orthop Sci 2016; 21:389-94. [PMID: 26740441 DOI: 10.1016/j.jos.2015.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 10/16/2014] [Accepted: 11/25/2014] [Indexed: 10/23/2022]
Affiliation(s)
- Jaroslaw Czekaj
- Departement of Orthopaedics, Hospital Payerne, Avenue de la Colline 3, 1530 Payerne, Switzerland.
| | - Matthieu Ehlinger
- Department of Orthopaedic Surgery and Traumatology, Hautepierre Hospital, Strasbourg University Hospitals Group, 1 Avenue Molière, 67098 Strasbourg, France
| | - Michel Rahme
- Department of Orthopaedic Surgery and Traumatology, Hautepierre Hospital, Strasbourg University Hospitals Group, 1 Avenue Molière, 67098 Strasbourg, France
| | - Francois Bonnomet
- Department of Orthopaedic Surgery and Traumatology, Hautepierre Hospital, Strasbourg University Hospitals Group, 1 Avenue Molière, 67098 Strasbourg, France
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Giampreti A, Lonati D, Ragghianti B, Ronchi A, Petrolini VM, Vecchio S, Locatelli CA. N-Acetyl-Cysteine as Effective and Safe Chelating Agent in Metal-on-Metal Hip-Implanted Patients: Two Cases. Case Rep Orthop 2016; 2016:8682737. [PMID: 27148463 PMCID: PMC4842352 DOI: 10.1155/2016/8682737] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/20/2016] [Indexed: 01/06/2023] Open
Abstract
Systemic toxicity associated with cobalt (Co) and chromium (Cr) containing metal hip alloy may result in neuropathy, cardiomyopathy, and hypothyroidism. However clinical management concerning chelating therapy is still debated in literature. Here are described two metal-on-metal hip-implanted patients in which N-acetyl-cysteine decreased elevated blood metal levels. A 67-year-old male who underwent Co/Cr hip implant in September 2009 referred to our Poison Control Centre for persisting elevated Co/Cr blood levels (from March 2012 to November 2014). After receiving oral high-dose N-acetyl-cysteine, Co/Cr blood concentrations dropped by 86% and 87% of the prechelation levels, respectively, and persisted at these latter concentrations during the following 6 months of follow-up. An 81-year-old female who underwent Co/Cr hip implant in January 2007 referred to our Centre for detection of high Co and Cr blood levels in June 2012. No hip revision was indicated. After a therapy with oral high-dose N-acetyl-cysteine Co/Cr blood concentrations decreased of 45% and 24% of the prechelation levels. Chelating agents reported in hip-implanted patients (EDTA, DMPS, and BAL) are described in few cases. N-acetyl-cysteine may provide chelating sites for metals and in our cases reduced Co and Cr blood levels and resulted well tolerable.
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Affiliation(s)
- Andrea Giampreti
- Pavia Poison Centre and National Toxicology Information Centre, IRCCS Maugeri Foundation Clinical Institute and University of Pavia, 27100 Pavia, Italy
| | - Davide Lonati
- Pavia Poison Centre and National Toxicology Information Centre, IRCCS Maugeri Foundation Clinical Institute and University of Pavia, 27100 Pavia, Italy
| | | | - Anna Ronchi
- Pavia Poison Centre and National Toxicology Information Centre, IRCCS Maugeri Foundation Clinical Institute and University of Pavia, 27100 Pavia, Italy
| | - Valeria Margherita Petrolini
- Pavia Poison Centre and National Toxicology Information Centre, IRCCS Maugeri Foundation Clinical Institute and University of Pavia, 27100 Pavia, Italy
| | - Sarah Vecchio
- Pavia Poison Centre and National Toxicology Information Centre, IRCCS Maugeri Foundation Clinical Institute and University of Pavia, 27100 Pavia, Italy
| | - Carlo Alessandro Locatelli
- Pavia Poison Centre and National Toxicology Information Centre, IRCCS Maugeri Foundation Clinical Institute and University of Pavia, 27100 Pavia, Italy
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Zywiel MG, Cherian JJ, Banerjee S, Cheung AC, Wong F, Butany J, Gilbert C, Overgaard C, Syed K, Jacobs JJ, Mont MA. Systemic cobalt toxicity from total hip arthroplasties. Bone Joint J 2016; 98-B:14-20. [PMID: 26733510 DOI: 10.1302/0301-620x.98b1.36712] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
As adverse events related to metal on metal hip arthroplasty have been better understood, there has been increased interest in toxicity related to the high circulating levels of cobalt ions. However, distinguishing true toxicity from benign elevations in cobalt levels can be challenging. The purpose of this review is to examine the use of cobalt alloys in total hip arthroplasty, to review the methods of measuring circulating cobalt levels, to define a level of cobalt which is considered pathological and to review the pathophysiology, risk factors and treatment of cobalt toxicity. To the best of our knowledge, there are 18 published cases where cobalt metal ion toxicity has been attributed to the use of cobalt-chromium alloys in hip arthroplasty. Of these cases, the great majority reported systemic toxic reactions at serum cobalt levels more than 100 μg/L. This review highlights some of the clinical features of cobalt toxicity, with the goal that early awareness may decrease the risk factors for the development of cobalt toxicity and/or reduce its severity. Take home message: Severe adverse events can arise from the release of cobalt from metal-on-metal arthroplasties, and as such, orthopaedic surgeons should not only be aware of the presenting problems, but also have the knowledge to treat appropriately. Cite this article: Bone Joint J 2016;98-B:14–20.
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Affiliation(s)
- M. G. Zywiel
- University of Toronto, 100
College Street Room 302, Toronto, Ontario, M5G
1L5, Canada
| | - J. J. Cherian
- Philadelphia College of Osteopathic Medicine, 4190
City Line Ave, Philadelphia, PA
19131, USA
| | - S. Banerjee
- Sinai Hospital of Baltimore, 2401
West Belvedere Avenue, Baltimore, MD 21215, USA
| | - A. C. Cheung
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - F. Wong
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - J. Butany
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - C. Gilbert
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - C. Overgaard
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - K. Syed
- University of Toronto, 100
College Street Room 302, Toronto, Ontario, M5G
1L5, Canada
| | - J. J. Jacobs
- Rush
University, 1611 W. Harrison St., Suite
400, Chicago, IL, 60612, USA
| | - M. A. Mont
- Sinai Hospital of Baltimore, 2401
West Belvedere Avenue, Baltimore, MD 21215, USA
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Clinical manifestations in ten patients with asymptomatic metal-on-metal hip arthroplasty with very high cobalt levels. Hip Int 2015; 23:441-4. [PMID: 23813157 DOI: 10.5301/hipint.5000054] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2013] [Indexed: 02/04/2023]
Abstract
Reports of adverse reactions to metal particle debris with metal-on-metal (MoM) hip arthroplasty have increased recently. Apart from the formation of pseudotumours and higher revision rates, another major cause for concern are the systemic effects of metal ions. Several effects of elevated systemic cobalt ions have been reported (e.g., myocardial and neurological effects, hypothyroidism). All 643 patients who underwent a stemmed large head MoM total hip replacement in our clinic were screened with repeated whole blood samples of metal ions (cobalt, chromium). We included ten asymptomatic unrevised patients with the highest cobalt concentrations, determined at a minimum of three years after implantation. These patients were subjected to an extensive neurological and cardiological screening protocol. In addition, blood samples were taken to assess renal and thyroid function. Ten patients with a cobalt level of 18-153 µg/L (mean 46.8 µg/L) were included. Nine patients were female, mean age was 65 years (range 56-75). The mean follow-up period was 4.2 years (range 3.0-6.1). Seven patients had bilateral stemmed MoM hip arthroplasty. No signs or symptoms of neurological dysfunction, cardiomyopathy, or renal or thyroid dysfunction could be identified or attributed to elevated cobalt levels. The clinical relevance of this study is that after short-term follow-up highly elevated blood cobalt levels do not cause systemic effects in our population. Hence in asymptomatic patients metal ions appear not to be a significant factor in the decision of when to revise a MoM large head total hip replacement.
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Self-reported neurological clinical manifestations of metal toxicity in metal-on-metal hip arthroplasty. Hip Int 2014; 24:568-74. [PMID: 25096449 DOI: 10.5301/hipint.5000179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2014] [Indexed: 02/04/2023]
Abstract
Adverse reactions to metal particle debris have been increasingly reported as a complication following large head metal-on-metal (MoM) hip arthroplasty. Elevated metal ion levels are a cause for concern. The aim of this study is to evaluate whether exposure to cobalt is associated with patient characteristics and symptoms of neuropathy, representing nervous system dysfunction. A cross-sectional study was conducted comparing patients with a MoM total hip arthroplasty and patients with a conventional hip arthroplasty. They received three questionnaires, one to assess neurotoxic complaints and two standardised self-administered questionnaires to identify symptoms that are suggestive of peripheral neuropathy. Current and historical data were available for whole blood cobalt levels in all patients. We analysed potential predictive factors for cobalt based on five different cut-off levels (0-2, 2-4, 4-10, 10-20, >20 µg/L). We performed 723 MoM total hip arthroplasties in 643 patients in our clinic. The response rate was 89%. Male-female ratio was 236/280, median age 63.6 years (30-72) with a mean follow-up of 50.6 months (20-86). We also sent the questionnaires to 98 patients in the control group. An increase in the incidence of reported symptoms was not consistent with higher serum cobalt levels. Female gender was the only consistent predictive factor for serum cobalt at different cobalt cut-off levels in the multivariate analysis. The study population did not show an increase in reported symptoms with elevated cobalt levels. Neurotoxic symptoms and whole blood cobalt levels did not show a consistent relationship with different dichotomised levels of cobalt exposure.
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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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Abstract
INTRODUCTION One in eight of all total hip replacements requires revision within 10 years, 60% because of wear-related complications. The bearing surfaces may be made of cobalt/chromium, stainless steel, ceramic, or polyethylene. Friction between bearing surfaces and corrosion of non-moving parts can result in increased local and systemic metal concentrations. OBJECTIVES To identify and systematically review published reports of systemic toxicity attributed to metal released from hip implants and to propose criteria for the assessment of these patients. METHODS Medline (from 1950) and Embase (from 1980) were searched to 28 February 2014 using the search terms (text/abstract) chrom* or cobalt* and [toxic* or intox* or poison* or adverse effect or complication] and [prosthes* or 'joint replacement' or hip or arthroplast*] and PubMed (all available years) was searched using the search term (("Chromium/adverse effects"[Mesh] OR "Chromium/poisoning"[Mesh] OR "Chromium/toxicity"[Mesh]) OR ("Cobalt/adverse effects"[Mesh] OR "Cobalt/poisoning"[Mesh] OR "Cobalt/toxicity"[Mesh])) AND ("Arthroplasty, Replacement, Hip"[Mesh] OR "Hip Prosthesis"[Mesh]). These searches identified 281 unique references, of which 23 contained original case data. Three further reports were identified from the bibliographies of these papers. As some cases were reported repeatedly the 26 papers described only 18 individual cases. Systemic toxicity. Ten of these eighteen patients had undergone revision from a ceramic-containing bearing to one containing a metal component. The other eight had metal-on-metal prostheses. Systemic toxicity was first manifest months and often several years after placement of the metal-containing joint. The reported systemic features fell into three main categories: neuro-ocular toxicity (14 patients), cardiotoxicity (11 patients) and thyroid toxicity (9 patients). Neurotoxicity was manifest as peripheral neuropathy (8 cases), sensorineural hearing loss (7) and cognitive decline (5); ocular toxicity presented as visual impairment (6). All these neurological features, except cognitive decline, have been associated with cobalt poisoning previously. Type of prosthesis and blood metal concentrations. Where blood or serum metal concentrations were reported (n = 17 for cobalt and n = 14 for chromium), the median cobalt concentration was 398 (range, 13.6-6521) μg/L and the median chromium concentration was 48 μg/L (in whole blood) (range, 4.1-221 μg/L including serum and blood values). Those patients reported to have systemic features who had received a metal-on-metal prosthesis (n = 8) had a median peak blood cobalt concentration of 34.5 (range, 13.6-398.6) μg/L; those with a metal-containing revision of a failed ceramic prosthesis (n = 10) had a median blood cobalt concentration of 506 (range, 353-6521) μg/L. Management. The most common treatment was removal of the metal-containing prosthesis, undertaken in all but 2 patients. This was usually associated with a fall in circulating cobalt concentration and improvement in some or all features. Clinical and toxicological assessment of systemic features. We propose the following criteria for assessing the likelihood that clinical features are related to cobalt toxicity: clinical effects consistent with the known neurological, cardiac, or thyroidal effects of cobalt, and for which any other explanation is less likely; increased blood cobalt concentrations (substantially higher than those in patients with well-functioning prostheses) several months after hip replacement; a fall in the blood cobalt concentration, usually accompanied by signs of improvement in features. When judged by these criteria, the systemic features in 10 of the reported cases are likely to be related to cobalt exposure from a metal-containing hip prosthesis. CONCLUSIONS Rarely, patients exposed to high circulating concentrations of cobalt from failed hip replacements develop neurological damage, hypothyroidism and/or cardiomyopathy, which may not resolve completely even after removal of the prosthesis. The greatest risk of systemic cobalt toxicity seems to result from accelerated wear of a cobalt-containing revision of a failed ceramic prosthesis, rather than from primary failure of a metal-on-metal prosthesis.
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Affiliation(s)
- S M Bradberry
- West Midlands Poisons Unit, City Hospital , Birmingham , UK
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Monnot AD, Christian WV, Paustenbach DJ, Finley BL. Correlation of blood Cr(III) and adverse health effects: Application of PBPK modeling to determine non-toxic blood concentrations. Crit Rev Toxicol 2014; 44:618-37. [DOI: 10.3109/10408444.2014.926472] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
These proceedings will review the role of chelation in five metals-aluminum, cadmium, chromium, cobalt, and uranium-in order to illustrate various chelation concepts. The process of "chelation" can often be oversimplified, leading to incorrect assumptions and risking patient harm. For chelation to be effective, two critical assumptions must be fulfilled: the presumed "metal toxicity" must correlate with a given body or a particular compartment burden, and reducing this compartmental or the body burden (through chelation) attenuates toxicity. Fulfilling these assumptions requires an established dose-response relationship, a validated, reproducible means of toxicity assessment (clinical, biochemical, or radiographical), and an appropriate assessment mechanisms of body or compartment burden. While a metal might "technically" be capable of chelation (and readily demonstrable in urine or feces), this is an insufficient endpoint. Clinical relevance must be affirmed. Deferoxamine is an accepted chelator for appropriately documented aluminum toxicity. There is a very minimal treatment window in order to address chelation in cadmium toxicity. In acute toxicity, while no definitive chelation benefit is described, succimer (DMSA), diethylenetriaminepentaacetate (DTPA), and potentially ethylenediaminetetraacetic acid (EDTA) have been considered. In chronic toxicity, chelation is unsupported. There is little evidence to suggest that currently available chromium chelators are efficacious. Similarly, scant human evidence exists with which to provide recommendation for cobalt chelation. DTPA has been recommended for cobalt radionuclide chelation, although DMSA, EDTA, and N-acetylcysteine have also been suggested. DTPA is unsupported for uranium chelation. Sodium bicarbonate is currently recommended, although animal evidence is conflicting.
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Affiliation(s)
- Silas W Smith
- Department of Emergency Medicine, Division of Medical Toxicology, New York University School of Medicine, New York, NY, USA,
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Devlin JJ, Pomerleau AC, Brent J, Morgan BW, Deitchman S, Schwartz M. Clinical features, testing, and management of patients with suspected prosthetic hip-associated cobalt toxicity: a systematic review of cases. J Med Toxicol 2013; 9:405-15. [PMID: 24222555 PMCID: PMC3846976 DOI: 10.1007/s13181-013-0320-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Safety concerns regarding cobalt-containing metal alloy hip prosthetics (Co-HP) have resulted in product recalls, a medical device alert, and issuance of guidance for clinicians. Recently, cases of suspected prosthetic hip-associated cobalt toxicity (PHACT) from Co-HP have been reported. Although little is known about suspected PHACT, these patients may be referred to medical toxicologists for evaluation and management recommendations. We searched MEDLINE, EMBASE, and unpublished abstracts from toxicology scientific meetings for references relevant to PHACT. Authors independently screened publications for inclusion criteria: publication in English, human study population, subject(s) are symptomatic (except for isolated hip pain), and cobalt values in any matrix (blood, serum, urine, CSF, synovial fluid) available for review. Data from 10 cases are reviewed. Patients with suspected PHACT had findings consistent with cobalt toxicity, including thyroid, cardiac, and neurologic dysfunction. Signs and symptoms appeared between 3 and 72 months after arthroplasty (median 19 months). Neurologic symptoms were most common. Ancillary testing varied considerably. All patients had elevated cobalt levels in one or more matrices. Enhanced elimination was attempted in 27 % of patients. At this time, the information currently available regarding patients with suspected PHACT is inadequate to guide clinical decision making. No consensus has been reached regarding the management of Co-HP patients with systemic symptoms. Indications for chelation have not been established and require further study. Improved case definitions, improved surveillance, and controlled studies are needed to elucidate the scope of this problem and guide future investigations.
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Affiliation(s)
- John J Devlin
- Georgia Poison Center, 50 Hurt Plaza, Suite 600, Atlanta, GA, 30303, USA,
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Abstract
PURPOSE OF REVIEW Many causes of toxic optic neuropathy have been described to date and novel causes of toxicity are continuously being added to the current literature. The pathophysiological basis for the toxicity or a direct causal relationship is yet to be determined for many of these agents. This review highlights the reports made over the last year about the commonly reported agents, with emphasis on the mechanisms of toxicity. RECENT FINDINGS Mitochondria of retinal ganglion cells and papillomacular bundle in particular could be the common target of many causes of toxic optic neuropathy, if not all. Agents or their metabolites responsible for the toxicity seem to interfere with the oxidative phosphorylation in mitochondria, causing a buildup of reactive oxidation species, energy depletion, oxidative stress, and activation of apoptosis. SUMMARY Further data are still necessary to understand how some of the usual suspects cause damage to the optic nerve or whether they indeed cause damage or not. A basic algorithm, as proposed, could be a useful addition to discriminate the novel causes of toxic optic neuropathy. VIDEO ABSTRACT See the Supplemental Digital Content 1 (http://links.lww.com/COOP/A11).
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Paustenbach DJ, Galbraith DA, Finley BL. Interpreting cobalt blood concentrations in hip implant patients. Clin Toxicol (Phila) 2013; 52:98-112. [DOI: 10.3109/15563650.2013.857024] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Apostoli P, Catalani S, Zaghini A, Mariotti A, Poliani PL, Vielmi V, Semeraro F, Duse S, Porzionato A, Macchi V, Padovani A, Rizzetti MC, De Caro R. High doses of cobalt induce optic and auditory neuropathy. ACTA ACUST UNITED AC 2013; 65:719-27. [DOI: 10.1016/j.etp.2012.09.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 07/27/2012] [Accepted: 09/19/2012] [Indexed: 11/29/2022]
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40
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Devlin JJ, Schwartz M, Brent J. Chelation in suspected prosthetic hip-associated cobalt toxicity. Can J Cardiol 2013; 29:1533.e7. [PMID: 23773894 DOI: 10.1016/j.cjca.2013.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 03/25/2013] [Accepted: 03/25/2013] [Indexed: 11/16/2022] Open
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Paustenbach DJ, Tvermoes BE, Unice KM, Finley BL, Kerger BD. A review of the health hazards posed by cobalt. Crit Rev Toxicol 2013; 43:316-62. [DOI: 10.3109/10408444.2013.779633] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Cooper HJ, Jacobs JJ, Leikin JB, Barden RM, Rosenberg AG. Elevated Serum Metal Levels from Vitamin Supplementation: A Case Report. JBJS Case Connect 2013; 3:e18. [PMID: 29252323 DOI: 10.2106/jbjs.cc.l.00211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- H John Cooper
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612.
| | - Joshua J Jacobs
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612.
| | - Jerrold B Leikin
- NorthShore University HealthSystem, 2150 Pfingsten Road, Glenview, IL 60026
| | - Regina M Barden
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612.
| | - Aaron G Rosenberg
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612.
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Abstract
BACKGROUND Saving bone by resurfacing the femoral head is not a new concept and the appeal for this type of hip replacement has remained despite the difficulties to find a bearing material suitable for this procedure. PURPOSE In this article, the unique experience of a surgeon who has been performing hip resurfacing since its early development is presented, along with a comparative analysis of the performance of successive designs. RESULTS The overall 10-year Kaplan-Meier survivorship of the early designs with polyethylene bearings did not exceed 62% while that of the current Conserve®Plus metal-on-metal hybrid design implanted with second generation surgical technique is in excess of 92%. Further exceptional, in the 10-year survivorship, 99.7% has been achieved with femoral size of 46 mm and good bone quality. Cementless acetabular components provide better enduring fixation than cemented designs. DISCUSSION Metal-on-metal is currently and fortunately the only highly successful bearing material that can combine low wear rates and the manufacturing of a thin acetabular component to preserve bone and still accommodate the large femoral head of a hip resurfacing. The adverse local tissue reactions (ALTR) associated with metal-on-metal devices are not a bearing material issue per se but one of the device design and surgical technique. Almost all of ALTR and the rare events of systemic toxicity are due to abnormal wear patterns which can be prevented by proper acetabular component design and precise socket orientation in both the coronal and sagittal planes. Further improvements of the long-term durability with hip resurfacing can be anticipated with the use of recently developed trabecular bone-like tantalum or titanium porous coatings and with proper training of the surgeons interested in performing hip resurfacing arthroplasty.
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Affiliation(s)
- Harlan C Amstutz
- Joint Replacement Institute at Saint Vincent Medical Center, The S. Mark Taper Building, 2200 West Third Street, Suite 400, Los Angeles, CA 90057 USA
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Newton AW, Ranganath L, Armstrong C, Peter V, Roberts NB. Differential distribution of cobalt, chromium, and nickel between whole blood, plasma and urine in patients after metal-on-metal (MoM) hip arthroplasty. J Orthop Res 2012; 30:1640-6. [PMID: 22447496 DOI: 10.1002/jor.22107] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 03/01/2012] [Indexed: 02/04/2023]
Abstract
Evidence shows that raised cobalt (Co), chromium (Cr), and nickel (Ni) whole blood concentrations correlate with poor device outcome in patients following metal-on-metal (MoM) hip arthroplasty. To understand the local and systemic pathological effects of these raised metal concentrations it is important to define their distribution between whole blood, plasma, and urine. The metals were measured by Inductively Coupled Plasma Mass Spectrometry (ICPMS). Two hundred and five plasma, 199 whole blood, and 24 sets of urine samples were analyzed from 202 patients with Co-Cr alloy MoM hip prostheses implanted between 8 months to 12 years (mean 6.0 years) prior to analysis. Plasma Co (median 39.1 nmol/L) showed significantly positive 1:1 correlation with whole blood Co (median 45.9 nmol/L; R(2) = 0.98, p < 0.001, slope = 1.0). Plasma Cr (median 53.8 nmol/L) and whole blood Cr (median 40.3 nmol/L) were also correlated; however, concentrations were significantly higher in plasma indicating relatively little blood cell uptake (R(2) = 0.96, p < 0.001, slope = 1.6). Urinary Co was up to threefold higher than Cr (median 334.0 vs. 97.3 nmol/L respectively). Nickel concentrations in whole blood, plasma, and urine were low relative to Co and Cr. The analysis shows fundamental differences in the physiological handling of these metals: Co is distributed approximately equally between blood cells and plasma, whereas Cr is mainly in plasma, despite which, Cr had far less renal excretion than Co.
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Affiliation(s)
- Ashley W Newton
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, University of Liverpool, Prescot Street, Liverpool L7 8XP, United Kingdom.
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Maurer-Ertl W, Friesenbichler J, Sadoghi P, Pechmann M, Trennheuser M, Leithner A. Metal ion levels in large-diameter total hip and resurfacing hip arthroplasty--preliminary results of a prospective five year study after two years of follow-up. BMC Musculoskelet Disord 2012; 13:56. [PMID: 22494794 PMCID: PMC3490776 DOI: 10.1186/1471-2474-13-56] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 03/27/2012] [Indexed: 01/15/2023] Open
Abstract
Background Metal-on-metal hip resurfacing is an alternative to metal-on-metal total hip arthroplasty, especially for young and physically active patients. However, wear which might be detected by increased serum ion levels is a matter of concern. Methods The aims of this preliminary study were to determine the raise of metal ion levels at 2-years follow-up in a prospective setting and to evaluate differences between patients with either resurfacing or total hip arthroplasty. Furthermore we investigated if the inclination of the acetabular component and the arc of cover would influence these findings. Therefore, 36 patients were followed prospectively. Results The results showed increments for Co and Cr in both implant groups. Patients treated with large-diameter total hip arthroplasty showed fourfold and threefold, respectively, higher levels for Co and Cr compared to the resurfacing group (Co: p < 0,001 and Cr: p = 0,005). Nevertheless, we observed no significant correlation between serum ion levels, inclination and arc of cover. Discussion In order to clarify the biologic effects of ion dissemination and to identify risks concerning long-term toxicity of metals, the exposure should be monitored carefully. Therefore, long-term studies have to be done to determine adverse effects of Co and Cr following metal-on-metal hip replacement.
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Affiliation(s)
- W Maurer-Ertl
- Department of Orthopaedic Surgery, Medical University of Graz, Graz, Austria
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