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Lachance AD, Stogsdill PB, McGrory BJ. Late Hematogenous Total Hip Infection After Revision for Mechanically Assisted Crevice Corrosion With Adverse Local Tissue Reaction. Arthroplast Today 2022; 18:173-180. [PMID: 36387330 PMCID: PMC9647085 DOI: 10.1016/j.artd.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 11/08/2022] Open
Abstract
Mechanically assisted crevice corrosion (MACC) at the trunnion-bore junction of a total hip arthroplasty may cause adverse local tissue reaction (ALTR) with inflammatory reaction and tissue necrosis. Complications, including acute infection, continued pain, and instability, are therefore common after a revision surgery for MACC. We now present 2 cases of late hematogenous bacterial infection years after revision for MACC and ALTR, a previously unreported outcome in this population. We hypothesize that MACC-induced tissue necrosis does not heal over time, and some patients with metal-on-polyethylene total hip arthroplasty treated for ALTR are at long-term risk of hematogenous bacterial infection.
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Hodges NA, Sussman EM, Stegemann JP. Aseptic and septic prosthetic joint loosening: Impact of biomaterial wear on immune cell function, inflammation, and infection. Biomaterials 2021; 278:121127. [PMID: 34564034 DOI: 10.1016/j.biomaterials.2021.121127] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 12/17/2022]
Abstract
The success of total joint replacements has led to consistent growth in the use of arthroplasty in progressively younger patients. However, more than 10 percent of patients require revision surgeries due to implant failure caused by osteolytic loosening. These failures are classified as either aseptic or septic and are associated with the presence of particulate wear debris generated by mechanical action between implant components. Aseptic loosening results from chronic inflammation caused by activation of resident immune cells in contact with implant wear debris. In contrast, septic loosening is defined by the presence of chronic infection at the implant site. However, recent findings suggest that subclinical biofilms may be overlooked when evaluating the cause of implant failure, leading to a misdiagnosis of aseptic loosening. Many of the inflammatory pathways contributing to periprosthetic joint infections are also involved in bone remodeling and resorption. In particular, wear debris is increasingly implicated in the inhibition of the innate and adaptive immune response to resolve an infection or prevent hematogenous spread. This review examines the interconnectivity of wear particle- and infection-associated mechanisms of implant loosening, as well as biomaterials-based strategies to combat infection-related osteolysis.
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Affiliation(s)
- Nicholas A Hodges
- University of Michigan, Department of Biomedical Engineering, Ann Arbor, MI, 48109, USA; Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, FDA, Silver Spring, MD, 20993, USA.
| | - Eric M Sussman
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, FDA, Silver Spring, MD, 20993, USA.
| | - Jan P Stegemann
- University of Michigan, Department of Biomedical Engineering, Ann Arbor, MI, 48109, USA.
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Aboltins CA, Antoci V, Bhattacharyya S, Cross M, Ducheyne P, Freiberg AA, Hailer N, Kay P, Ketonis C, Klement MR, Köse N, Lee M, Mitchell P, Nandi S, Palacio JC, Perry K, Prieto H, Shahi A, Trebše R, Turner D, Wu CT, Yazdi H. Hip and Knee Section, Prevention, Prosthesis Factors: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S309-S320. [PMID: 30348551 DOI: 10.1016/j.arth.2018.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Bijukumar DR, Segu A, Souza JCM, Li X, Barba M, Mercuri LG, J Jacobs J, Mathew MT. Systemic and local toxicity of metal debris released from hip prostheses: A review of experimental approaches. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2018; 14:951-963. [PMID: 29339190 PMCID: PMC6017990 DOI: 10.1016/j.nano.2018.01.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 12/22/2017] [Accepted: 01/02/2018] [Indexed: 12/12/2022]
Abstract
Despite the technological improvements in orthopedic joint replacement implants, wear and corrosion products associated with the metal components of these implants may result in adverse local tissue and perhaps systemic reactions and toxicities. The current review encompasses a literature review of the local and systemic toxicity studies concerning the effect of CoCrMo wear debris released from wear and corrosion of orthopedic implants and prostheses. Release of metallic debris is mainly in the form of micro- and nano-particles, ions of different valences, and oxides composed of Co and Cr. Though these substances alter human biology, their direct effects of these substances on specific tissue types remain poorly understood. This may partially be the consequence of the multivariate research methodologies employed, leading to inconsistent reports. This review proposes the importance of developing new and more appropriate in-vitro methodologies to study the cellular responses and toxicity mediated by joint replacement wear debris in-vivo.
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Affiliation(s)
- Divya Rani Bijukumar
- Regenerative Medicine and Disability Research Lab, Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, IL, USA
| | - Abhijith Segu
- Regenerative Medicine and Disability Research Lab, Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, IL, USA
| | - Júlio C M Souza
- Center for MicroElectromechanical Systems (CMEMS-UMINHO), University of Minho, Guimaraes, Portugal
| | - XueJun Li
- Regenerative Medicine and Disability Research Lab, Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, IL, USA
| | - Mark Barba
- Regenerative Medicine and Disability Research Lab, Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, IL, USA; OrthoIllinois, Rockford, IL, USA
| | - Louis G Mercuri
- Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA
| | - Joshua J Jacobs
- Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA
| | - Mathew Thoppil Mathew
- Regenerative Medicine and Disability Research Lab, Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, IL, USA; Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA; Department of Bioengineering, University of Illinois at Chicago, IL, USA.
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Granchi D, Savarino LM, Ciapetti G, Baldini N. Biological effects of metal degradation in hip arthroplasties. Crit Rev Toxicol 2017; 48:170-193. [PMID: 29130357 DOI: 10.1080/10408444.2017.1392927] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metals and metal alloys are the most used materials in orthopedic implants. The focus is on total hip arthroplasty (THA) that, though well tolerated, may be associated with local and remote adverse effects in the medium-long term. This review aims to summarize data on the biological consequences of the metal implant degradation that have been attributed predominantly to metal-on-metal (MoM) THA. Local responses to metals consist of a broad clinical spectrum ranging from small asymptomatic tissue lesions to severe destruction of bone and soft tissues, which are designated as metallosis, adverse reactions to metal debris (ARMD), aseptic lymphocytic vasculitis associated lesion (ALVAL), and pseudotumors. In addition, the dissemination of metal particles and ions throughout the body has been associated with systemic adverse effects, including organ toxicity, cancerogenesis, teratogenicity, and immunotoxicity. As proved by the multitude of studies in this field, metal degradation may increase safety issues associated with THA, especially with MoM hip systems. Data collection regarding local, systemic and long-term effects plays an essential role to better define any safety risks and to generate scientifically based recommendations.
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Affiliation(s)
- Donatella Granchi
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Lucia Maria Savarino
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Gabriela Ciapetti
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Nicola Baldini
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy.,b Department of Biomedical and Neuromotor Science , University of Bologna , Bologna , Italy
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Vasconcelos DM, Santos SG, Lamghari M, Barbosa MA. The two faces of metal ions: From implants rejection to tissue repair/regeneration. Biomaterials 2016; 84:262-275. [DOI: 10.1016/j.biomaterials.2016.01.046] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 12/20/2022]
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Corrosion and Adverse Local Tissue Reaction in One Type of Modular Neck Stem. J Arthroplasty 2015; 30:1787-93. [PMID: 26027523 DOI: 10.1016/j.arth.2015.04.039] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 03/19/2015] [Accepted: 04/20/2015] [Indexed: 02/01/2023] Open
Abstract
Modular neck stems allow for optimization of joint biomechanics by restoring anteversion, offset, and limb length. A potential disadvantage is the generation of metal ions from fretting and crevice corrosion. We identified 118 total hip arthroplasty implanted with one type of dual-modular femoral component. Thirty-six required revision due to adverse local tissue reaction. Multivariate analysis isolated females and low offset necks as risk factors for failure. Kaplan-Meir analysis revealed small stem sizes failed at a higher rate during early follow-up period. Although the cobalt/chrome levels were higher in the failed group, these tests had low diagnostic accuracy for ALTR, while MRI scan was more sensitive. We conclude that the complications related to the use of dual modular stems of this design outweigh the potential benefits.
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Madl AK, Kovochich M, Liong M, Finley BL, Paustenbach DJ, Oberdörster G. Toxicology of wear particles of cobalt-chromium alloy metal-on-metal hip implants Part II: Importance of physicochemical properties and dose in animal and in vitro studies as a basis for risk assessment. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2015; 11:1285-98. [PMID: 25735266 DOI: 10.1016/j.nano.2015.02.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 12/03/2014] [Indexed: 12/28/2022]
Abstract
The objective of the Part II analysis was to evaluate animal and in vitro toxicology studies of CoCr particles with respect to their physicochemistry and dose relevance to metal-on-metal (MoM) implant patients as derived from Part I. In the various toxicology studies, physicochemical characteristics were infrequently considered and administered doses were orders of magnitude higher than what occurs in patients. Co was consistently shown to rapidly release from CoCr particles for distribution and elimination from the body. CoCr micron sized particles appear more biopersistent in vivo resulting in inflammatory responses that are not seen with similar mass concentrations of nanoparticles. We conclude, that in an attempt to obtain data for a complete risk assessment, future studies need to focus on physicochemical characteristics of nano and micron sized particles and on doses and dose metrics relevant to those generated in patients or in properly conducted hip simulator studies.
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Affiliation(s)
| | | | | | | | | | - Günter Oberdörster
- University of Rochester, Department of Environmental Medicine, Rochester, NY, USA
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Prieto HA, Berbari EF, Sierra RJ. Acute delayed infection: increased risk in failed metal on metal total hip arthroplasty. J Arthroplasty 2014; 29:1808-12. [PMID: 24851788 DOI: 10.1016/j.arth.2014.04.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 03/31/2014] [Accepted: 04/06/2014] [Indexed: 02/01/2023] Open
Abstract
Adverse local tissue reactions occurring in metal-on-metal total hip arthroplasty (MoM THA) could potentially lead to secondary failure modes such as dislocation or infection. The authors report a series of 124 patients treated with MoM hip arthroplasty between 2006 and 2010 with a minimum follow-up of 3 years. Eight hips presented with acute delayed or late periprosthetic joint infection (PJI) (defined as an infection occurring after 3 months in an otherwise well functioning implant). The rate of infection observed was higher than expected, almost 4 times higher (5.6%) compared to previous historical cohorts from our institution (1.3%). This high risk of infection in patients with DePuy ASR implants requires further study but we theorize that the increased prevalence of infection could be due to a combination of particulate debris, molecular (rather than particulate) effects of Co and Cr ions on soft tissues, and/or products of corrosion that may change the local environment predisposing to infection.
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Affiliation(s)
- Hernan A Prieto
- Investigation performed at the Mayo Clinic, Rochester, Minnesota
| | - Elie F Berbari
- Investigation performed at the Mayo Clinic, Rochester, Minnesota
| | - Rafael J Sierra
- Investigation performed at the Mayo Clinic, Rochester, Minnesota
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Magnetic drug targeting reduces the chemotherapeutic burden on circulating leukocytes. Int J Mol Sci 2013; 14:7341-55. [PMID: 23549268 PMCID: PMC3645689 DOI: 10.3390/ijms14047341] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 03/08/2013] [Accepted: 03/08/2013] [Indexed: 11/17/2022] Open
Abstract
Magnetic drug targeting (MDT) improves the integrity of healthy tissues and cells during treatment with cytotoxic drugs. An anticancer drug is bound to superparamagnetic iron oxide nanoparticles (SPION), injected into the vascular supply of the tumor and directed into the tumor by means of an external magnetic field. In this study, we investigated the impact of SPION, mitoxantrone (MTO) and SPIONMTO on cell viability in vitro and the nonspecific uptake of MTO into circulating leukocytes in vivo. MDT was compared with conventional chemotherapy. MTO uptake and the impact on cell viability were assessed by flow cytometry in a Jurkat cell culture. In order to analyze MTO loading of circulating leukocytes in vivo, we treated tumor-bearing rabbits with MDT and conventional chemotherapy. In vitro experiments showed a dose-dependent MTO uptake and reduction in the viability and proliferation of Jurkat cells. MTO and SPIONMTO showed similar cytotoxic activity. Non-loaded SPION did not have any effect on cell viability in the concentrations tested. Compared with systemic administration in vivo, MDT employing SPIONMTO significantly decreased the chemotherapeutic load in circulating leukocytes. We demonstrated that MDT spares the immune system in comparison with conventional chemotherapy.
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Hussain S, Vanoirbeek JAJ, Hoet PHM. Interactions of nanomaterials with the immune system. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2011; 4:169-83. [DOI: 10.1002/wnan.166] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Salik Hussain
- Unit of Functional and Adaptive Biology, Laboratory of Molecular and Cellular Responses to Xenobiotics, Université Paris Diderot, Paris, France
- Research Unit for Lung Toxicology, K.U. Leuven, Leuven, Belgium
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Hailer NP, Blaheta RA, Dahlstrand H, Stark A. Elevation of circulating HLA DR(+) CD8(+) T-cells and correlation with chromium and cobalt concentrations 6 years after metal-on-metal hip arthroplasty. Acta Orthop 2011; 82:6-12. [PMID: 21189110 PMCID: PMC3229991 DOI: 10.3109/17453674.2010.548028] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Following metal-on-metal hip arthroplasty (THA), immunological reactions including changes in lymphocyte populations, aseptic loosening, and lymphocytic pseudotumors occur. We hypothesized that changes in lymphocyte subpopulations would be associated with elevated metal ion concentrations. METHODS A randomized trial involving 85 patients matched for age and sex and randomized to receiving metal-on-metal (n = 41) or metal-on-polyethylene total hip arthroplasty (n = 44) was conducted. 36 patients were eligible for follow-up after mean 7 (6-8) years. Concentrations of chromium and cobalt were analyzed by high-resolution inductively coupled plasma mass spectrometry. Leukocyte subpopulations and immunoglobulins in patient blood were measured using standard laboratory methods. RESULTS Patients with a metal-on-metal hip had higher serum concentrations of chromium (1.05 vs. 0.36 μg/L; p < 0.001) and cobalt (0.86 vs. 0.24 μg/L; p < 0.001) than those with metal-on-polyethylene. The percentage of HLA DR(+) CD8(+) T-cells was higher in the metal-on-metal group (10.6 vs. 6.7%; p = 0.03) and correlated positively with chromium and cobalt concentrations in patient blood (Pearson's correlation coefficient: 0.39, p = 0.02; 0.36, p = 0.03, respectively). The percentage of B-cells was lower in the metal-on-metal group (p = 0.01). The two groups were similar with respect to immunoglobulin concentrations and Harris hip scores, and there were no radiographic signs of loosening. INTERPRETATION We conclude that immunological alterations appear to be associated with increased cobalt and chromium concentrations. It is tempting to speculate that HLA DR(+) CD8(+) T-cells are involved in the pathogenesis of allergic reactions, implant loosening, and lymphocytic pseudotumors.
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Affiliation(s)
- Nils P Hailer
- Department of Orthopedics, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Roman A Blaheta
- Department of Urology, Goethe University, Frankfurt am Main, Germany
| | - Henrik Dahlstrand
- Department of Molecular Medicine and Surgery, Section of Orthopedics, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - André Stark
- Department of Molecular Medicine and Surgery, Section of Orthopedics, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Hosman AH, van der Mei HC, Bulstra SK, Busscher HJ, Neut D. Effects of metal-on-metal wear on the host immune system and infection in hip arthroplasty. Acta Orthop 2010; 81:526-34. [PMID: 20860450 PMCID: PMC3214739 DOI: 10.3109/17453674.2010.519169] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Joint replacement with metal-on-metal (MOM) bearings have gained popularity in the last decades in young and active patients. However, the possible effects of MOM wear debris and its corrosion products are still the subject of debate. Alongside the potential disadvantages such as toxicity, the influences of metal particles and metal ions on infection risk are unclear. METHODS We reviewed the available literature on the influence of degradation products of MOM bearings in total hip arthroplasties on infection risk. RESULTS Wear products were found to influence the risk of infection by hampering the immune system, by inhibiting or accelerating bacterial growth, and by a possible antibiotic resistance and heavy metal co-selection mechanism. INTERPRETATION Whether or not the combined effects of MOM wear products make MOM bearings less or more prone to infection requires investigation in the near future.
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Affiliation(s)
| | | | - Sjoerd K Bulstra
- Department of Orthopaedic Surgery, University Medical Center Groningen, Groningen, the Netherlands
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