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Gómez-Álvarez J, Miranda I, Álvarez-Llanas A, Lisón JF, Bosch-Morell F, Doménech J. Influence of Physical Activity and Cup Orientation on Metal Ion Release and Oxidative Stress in Metal-on-Metal and Ceramic-on-Metal Total Hip Arthroplasty. J Clin Med 2024; 13:527. [PMID: 38256664 PMCID: PMC10816639 DOI: 10.3390/jcm13020527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/30/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Metal-on-metal (M-M) total hip arthroplasty (THA) has shown adverse reactions to metal debris, abnormal soft-tissue reactions, and high blood metal ion levels. This study aims to: (1) assess whether the toxicity of high levels of ions is related to altered oxidative stress and (2) evaluate tribological factors related to increased blood levels of chromium (Cr) and cobalt (Co) ions. METHODS A cross-sectional analytical descriptive study was conducted on 75 patients. A total of 25 underwent M-M THA, 25 ceramic-on-metal (C-M) THA, and 25 were on the THA waiting list. Ion metallic levels in blood, oxidative stress, physical activity, and implant position were compared. RESULTS In the M-M group, Co and Cr levels were significantly higher than those found in the C-M group and the control group (p < 0.01). We found no differences in terms of oxidative stress between the groups. Also, we did not find a correlation between metal blood levels and oxidative stress indicators, the physical activity of the patients or the position of the implants between groups. CONCLUSIONS The use of M-M bearing surfaces in THA raises the levels of metals in the blood without modifying oxidative stress regardless of the physical activity levels of the patients. Therefore, although patients with M-M bearings require close monitoring, it does not seem necessary to recommend the restriction of physical activity in patients with M-M or C-M arthroplasties.
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Affiliation(s)
- Jorge Gómez-Álvarez
- Department of Orthopedic Surgery, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
| | - Ignacio Miranda
- Department of Orthopedic Surgery, Hospital Arnau de Vilanova, 46015 Valencia, Spain
- Faculty of Health Sciences, Universidad Católica de Valencia, 46001 Valencia, Spain
| | - Alejandro Álvarez-Llanas
- Department of Orthopedic Surgery, Hospital Arnau de Vilanova, 46015 Valencia, Spain
- Faculty of Health Sciences, Universidad Católica de Valencia, 46001 Valencia, Spain
| | - Juan F. Lisón
- Department of Biomedical Sciences, Faculty of Health Sciences, University CEU Cardenal Herrera, 46115 Alfara del Patriarca, Spain; (J.F.L.); (F.B.-M.)
- CIBER de Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Francisco Bosch-Morell
- Department of Biomedical Sciences, Faculty of Health Sciences, University CEU Cardenal Herrera, 46115 Alfara del Patriarca, Spain; (J.F.L.); (F.B.-M.)
| | - Julio Doménech
- Department of Orthopedic Surgery, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
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Miguela Alvarez SM, Luna Gutiérrez R, Surroca M, Bartra Ylla A, Angles Crespo F. [Translated article] Metal on metal total hip arthroplasty: Correlation between inclination of the acetabular and metal ion levels. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T233-T239. [PMID: 36863521 DOI: 10.1016/j.recot.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/04/2022] [Indexed: 03/04/2023] Open
Abstract
Due to their low friction index, hip arthroplasties with metal-metal (M-M) friction torque have been an attractive option in young patients with high functional demand, currently they have suffered a decrease in their use due to the complications of some models and physiological reactions adverse reactions related to the elevation of metal ions in the blood. Our objective is to review the patients with M-M pair operated in our centre, correlating the ion level with the position of the acetabular component and with the size of the head. MATERIAL AND METHODS Retrospective review of 166 M-M hip prostheses operated between 2002 and 2011. Sixty five ruled out for different causes (death, loss of follow-up, no current ion control, no radiography or others), leaving a sample of 101 patients to be analysed. Follow-up time, cup inclination angle, blood ion level, Harris Hip Score (HHS), and complications were recorded. RESULTS One hundred and one patients (25 women and 76 men), 55 years of average age (between 26 and 70), of these 8 were surface prostheses and 93 total prostheses. The mean follow-up time was 10 years (between 5 and 17 years). The mean head diameter was 46.25 (between 38 and 56). The mean inclination of the butts was 45.7° (between 26° and 71°). The correlation force between the verticality of the cup and the increase in ions is moderate r=0.31 for Cr and slight r=0.25 for Co. The correlation force between head size and ion increase is weak and inverse r=-0.14 for Cr and r=0.1 for Co. Five patients (4.9%) required revision (2 [1%] due to increased ions with pseudotumor). The mean time to revision was 6.5 years in which the ions increased. The mean HHS was 94.01 (between 55.8 and 100). In the review of patients, we found 3 with a significant increase in ions who had not followed controls, all 3 had an HHS of 100. The angles of the acetabular components were 69°, 60° and 48° and the diameter of the head was 48.42 and 48mm, respectively. DISCUSSION AND CONCLUSIONS M-M prostheses have been a valid option in patients with high functional demand. A bi-annual analytical follow-up is recommended, since in our case we have detected 3 patients with HHS 100 who presented unacceptable elevation of cobalt >20μm/l (according to SECCA) of the ions and 4 with very abnormal elevation of cobalt ≥10μm/l (according to SECCA), all of them with cup orientation angles >50°. With our review we can conclude that there is a moderate correlation between the verticality of the acetabular component and the increase in blood ions and that the follow-up of this patient with angles >50° is essential.
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Affiliation(s)
| | - R Luna Gutiérrez
- Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - M Surroca
- Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - A Bartra Ylla
- Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - F Angles Crespo
- Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
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Developing Patient-Specific Statistical Reconstructions of Healthy Anatomical Structures to Improve Patient Outcomes. Bioengineering (Basel) 2023; 10:bioengineering10020123. [PMID: 36829617 PMCID: PMC9952233 DOI: 10.3390/bioengineering10020123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
There are still numerous problems with modern joint replacement prostheses, which negatively influence patient health and recovery. For example, it is especially important to avoid failures and complications following hip arthroplasty because the loss of hip joint function is commonly associated with increased demand on the healthcare system, reoperation, loss of independence, physical disability, and death. The current study uses hip arthroplasty as a model system to present a new strategy of computationally generating patient-specific statistical reconstructions of complete healthy anatomical structures from computed tomography (CT) scans of damaged anatomical structures. The 3D model morphological data were evaluated from damaged femurs repaired with prosthetic devices and the respective damaged femurs that had been restored using statistical reconstruction. The results from all morphological measurements (i.e., maximum femoral length, Hausdorff distance, femoral neck anteversion, length of rotational center divergence, and angle of inclination) indicated that the values of femurs repaired with traditional prostheses did not fall within the +/-3 standard deviations of the respective patient-specific healthy anatomical structures. These results demonstrate that there are quantitative differences in the morphology of femurs repaired with traditional prostheses and the morphology of patient-specific statistical reconstructions. This approach of generating patient-specific statistical reconstructions of healthy anatomical structures might help to inform prosthetic designs so that new prostheses more closely resemble natural healthy morphology and preserve biomechanical function. Additionally, the patient-specific statistical reconstructions of healthy anatomical structures might be valuable for surgeons in that prosthetic devices could be selected and positioned to more accurately restore natural biomechanical function. All in all, this contribution establishes the novel approach of generating patient-specific statistical reconstructions of healthy anatomical structures from the CT scans of individuals' damaged anatomical structures to improve treatments and patient outcomes.
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Miguela Alvarez SM, Luna Gutiérrez R, Surroca M, Bartra Ylla A, Angles Crespo F. Metal on metal total hip arthroplasty: Correlation between inclination of the acetabular and metal ion levels. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 67:233-239. [PMID: 36513347 DOI: 10.1016/j.recot.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/27/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022] Open
Abstract
Due to their low friction index, hip arthroplasties with metal-metal (M-M) friction torque have been an attractive option in young patients with high functional demand, currently they have suffered a decrease in their use due to the complications of some models and physiological reactions adverse reactions related to the elevation of metal ions in the blood. Our objective is to review the patients with M-M pair operated in our center, correlating the ion level with the position of the acetabular component and with the size of the head. MATERIAL AND METHODS Retrospective review of 166 M-M hip prostheses operated between 2002 and 2011. Sixty five ruled out for different causes (death, loss of follow-up, no current ion control, no radiography or others), leaving a sample of 101 patients to be analyzed. Follow-up time, cup inclination angle, blood ion level, Harris Hip Score (HHS), and complications were recorded. RESULTS One hundred and one patients (25 women and 76 men), 55years of average age (between 26 and 70), of these 8 were surface prostheses and 93 total prostheses. The mean follow-up time was 10years (between 5 and 17years). The mean head diameters was 46.25 (between 38 and 56). The mean inclination of the butts was 45.7° (between 26° and 71°). The correlation force between the verticality of the cup and the increase in ions is moderate r=0.31 for Cr and slight r=0.25 for Co. The correlation force between head size and ion increase is weak and inverse r=-0.14 for Cr and r=0.1 for Co. Five patients (4.9%) required revision (2 [1%] due to increased ions with pseudotumor). The mean time to revision was 6.5years in which the ions increased. The mean HHS was 94.01 (between 55.8 and 100). In the review of patients, we found 3 with a significant increase in ions who had not followed controls, all 3 had an HHS of 100. The angles of the acetabular components were 69°, 60° and 48° and the diameter of the head was 48.42 and 48mm, respectively. DISCUSSION AND CONCLUSIONS M-M prostheses have been a valid option in patients with high functional demand. A bi-annual analytical follow-up is recommended, since in our case we have detected 3patients with HHS100 who presented unacceptable elevation of cobalt >20μm/L (according to SECCA) of the ions and 4 with very abnormal elevation of cobalt ≥10μm/L (according to SECCA), all of them with cup orientation angles >50°. With our review we can conclude that there is a moderate correlation between the verticality of the acetabular component and the increase in blood ions and that the follow-up of this patient with angles >50° is essential.
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Affiliation(s)
| | - R Luna Gutiérrez
- Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - M Surroca
- Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - A Bartra Ylla
- Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - F Angles Crespo
- Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
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Moreta J, Gayoso Ó, Donaire-Hoyas D, Roces-García J, Gómez-Vallejo J, Moya-Gómez E, Raya-Roldán D, Albert-Ullibarri A, Marqués-López F, Albareda J. Orthopedic Surgeons’ Accuracy When Orienting an Acetabular Cup. A Comparison with Untrained Individuals. Medicina (B Aires) 2022; 58:medicina58070973. [PMID: 35888692 PMCID: PMC9317603 DOI: 10.3390/medicina58070973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 06/29/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022] Open
Abstract
Background and Objectives: Previous studies demonstrated a huge variability among surgeons when it comes to reproducing the position of an acetabular cup in total hip arthroplasty. Our main objective is to determine if orthopedic surgeons can replicate a given orientation on a pelvic model better than untrained individuals. Our secondary objective is to determine if experience has any influence on their ability for this task. Materials and Methods: A group of specialist orthopedic hip surgeons and a group of volunteers with no medical training were asked to reproduce three given (randomly generated) acetabular cup orientations (inclination and anteversion) on a pelvic model. Error was measured by means of a hip navigation system and comparisons between groups were made using the appropriate statistical methods. Results: The study included 107 individuals, 36 orthopedic surgeons and 71 untrained volunteers. The mean error among surgeons was slightly greater as regards both inclination (7.84 ± 5.53 vs. 6.70 ± 4.03) and anteversion (5.85 ± 4.52 vs. 5.48 ± 3.44), although statistical significance was not reached (p = 0.226 and p = 0.639, respectively). Similarly, although surgeons with more than 100 procedures a year obtained better results than those with less surgical experience (8.01 vs. 7.67 degrees of error in inclination and 5.83 vs. 5.87 in anteversion), this difference was not statistically significant, either (p = 0.852 and p = 0.981). Conclusions: No differences were found in the average error made by orthopedic surgeons and untrained individuals. Furthermore, the surgeons’ cup orientation accuracy was not seen to improve significantly with experience.
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Affiliation(s)
- Jesús Moreta
- Department of Orthopedic Surgery and Traumatology, Hospital Galdakao-Usansolo, 48960 Galdakao, Spain
- Correspondence:
| | - Óscar Gayoso
- Department of Orthopedic Surgery and Traumatology, Hospital San Rafael, 15006 A Coruña, Spain;
| | - Daniel Donaire-Hoyas
- Department of Orthopedic Surgery and Traumatology, Hospital de Poniente, 04700 El Ejido, Spain; (D.D.-H.); (D.R.-R.); (A.A.-U.)
| | - Jorge Roces-García
- Department of Construction and Manufacturing Engineering, Polytechnic School of Engineering of Gijón, University of Oviedo, 33204 Gijón, Spain;
| | - Jesús Gómez-Vallejo
- Department of Orthopedic Surgery and Traumatology, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain; (J.G.-V.); (J.A.)
| | - Esther Moya-Gómez
- Department of Orthopedic Surgery and Traumatology, Hospital de la Santa Cruz y San Pablo, 08025 Barcelona, Spain;
| | - David Raya-Roldán
- Department of Orthopedic Surgery and Traumatology, Hospital de Poniente, 04700 El Ejido, Spain; (D.D.-H.); (D.R.-R.); (A.A.-U.)
| | - Alberto Albert-Ullibarri
- Department of Orthopedic Surgery and Traumatology, Hospital de Poniente, 04700 El Ejido, Spain; (D.D.-H.); (D.R.-R.); (A.A.-U.)
| | - Fernando Marqués-López
- Department of Orthopedic Surgery and Traumatology, Parc de Salut Mar, 08003 Barcelona, Spain;
| | - Jorge Albareda
- Department of Orthopedic Surgery and Traumatology, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain; (J.G.-V.); (J.A.)
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Radiographic Risk Factors Associated With Adverse Local Tissue Reaction in Head-Neck Taper Corrosion of Primary Metal-on-Polyethylene Total Hip Arthroplasty. J Am Acad Orthop Surg 2021; 29:353-360. [PMID: 32796372 DOI: 10.5435/jaaos-d-20-00473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/05/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Adverse local tissue reactions (ALTRs) in metal-on-polyethylene (MoP) total hip arthroplasty (THA) with head-neck taper corrosion are multifactorial, involving implant and patient factors. This study aimed to identify any potential clinical risk factors associated with failed MoP THA due to head-neck taper corrosion. METHODS A series of 146 MoP THA patients was investigated: (1) ALTR (n = 42) on metal artifact sequence MRI and (2) non-ALTR (n = 104). Both cohorts were compared regarding femoral neck shaft angle, acetabular implant orientation, component size, femoral head offset, measurement of medial and vertical femoral offsets, and femoral stem alloy. RESULTS The occurrence of ALTR was associated with increased radiographic femoral stem offset (36.0 ± 7.7 mm versus 40.8 ± 7.3 mm, P = 0.008), increased femoral head offset (0.7 ± 3.4 versus 4.5 ± 3.7, P < 0.001), and the use of Ti-12Mo-6Zr-2Fe alloy stems (P = 0.041). The presence of ALTR was notably associated with higher chromium (2.0 versus 0.5 μg/L) and cobalt (7.4 versus 0.7 μg/L, P < 0.001). DISCUSSION This study identified increased femoral head and stem offset and the use of Ti-12Mo-6Zr-2Fe alloy stems as risk factors for clinically relevant ALTR due to head-neck taper corrosion in MoP THA patients. This provides evidenced-based practical information for surgeons in identifying "at-risk" symptomatic MoP THA patients with head-neck taper corrosion for systematic risk stratification.
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Dias Corpa Tardelli J, Bolfarini C, Cândido Dos Reis A. Comparative analysis of corrosion resistance between beta titanium and Ti-6Al-4V alloys: A systematic review. J Trace Elem Med Biol 2020; 62:126618. [PMID: 32663743 DOI: 10.1016/j.jtemb.2020.126618] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/19/2020] [Accepted: 07/08/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND The knowledge of the electrochemical property (corrosion resistance) of beta titanium alloys compared to Ti-6Al-4 V for implants is relevant because of the potential cytotoxic effects that the released ions could cause to long-term health. OBJECTIVES The objective of this systematic review was to seek information on the electrochemical properties (corrosion resistance) of beta titanium alloys compared to Ti-6Al-4 V since the awareness of the electrochemical behavior of the implant surface in the medium is essential for the best indication of the alloys or compositional changes, which may promote benefits to bone-implant interaction in all areas that this procedure is required. METHODS The PubMed, LILACS, COCHRANE Library, and Science Direct databases were electronically searched for the terms: dental implants AND beta-titanium AND Ti-6Al-4 V AND electrochemical technics. The inclusion criteria were research articles that studied beta-titanium compared to Ti-6Al-4 V using electrochemical techniques in electrolytes of chemical composition similar to body fluid, published in English, between 2000 and 2020. Articles that did not compare the corrosion resistance of these alloys in electrolytes similar to body fluids were excluded. RESULTS A total of 189 articles were restored and selected by title and/or abstract according to the inclusion and exclusion criteria, which resulted in 15 articles that were reduced to 8 after read in full. The studies in vitro evaluated the corrosion resistance in electrolytes Hank, Ringer, SBF, and 0.9 % NaCl, between beta titanium alloys, obtained by arc fusion or bars stock, and Ti-6Al-4 V, for dental or biomedical implants submitted to surface treatments by heat treatment, plasma electrolytic oxidation (PEO), alkaline treatment, and thermomechanical. CONCLUSION The evaluated literature allowed to determine that 1) The oxides Nb2O 5, Ta2O 5, and ZrO2 have higher stability and protection quality than that of TiO2 modified by the oxides of Al and V; 2) A higher modulus of elasticity of the Ti-6Al-4 V alloy favors protection against corrosion by maintaining a thicker and more firmly adhered oxide layer; 3) The increase in the thickness of the Ti alloys superficial layer contributes to the improvement of the corrosion resistance.
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Affiliation(s)
- Juliana Dias Corpa Tardelli
- Department of Dental Materials and Prosthesis, School of Dentistry of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil.
| | - Claudemiro Bolfarini
- Department of Materials Engineering, Federal University of São Carlos (UFSCAR), São Carlos, SP, Brazil.
| | - Andréa Cândido Dos Reis
- Department of Dental Materials and Prosthesis, School of Dentistry of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil.
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Pozzuoli A, Berizzi A, Crimì A, Belluzzi E, Frigo AC, Conti GD, Nicolli A, Trevisan A, Biz C, Ruggieri P. Metal Ion Release, Clinical and Radiological Outcomes in Large Diameter Metal-on-Metal Total Hip Arthroplasty at Long-Term Follow-Up. Diagnostics (Basel) 2020; 10:diagnostics10110941. [PMID: 33198180 PMCID: PMC7698262 DOI: 10.3390/diagnostics10110941] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 02/08/2023] Open
Abstract
Total hip arthroplasty (THA) with metal-on-metal (MoM) bearings have shown problems of biocompatibility linked to metal ion release at the local level causing an adverse reaction to metal debris (ARMD) and at a systemic level. The aim of this study was to evaluate clinical and radiological outcomes, and metal ion concentrations in the blood and urine of patients who underwent THA with the LIMA Met-Met hip system. Patients with ceramic-on-ceramic (CoC) bearings were included as a control group. In this study, 68 patients were enrolled: 34 with MoM THAs and 34 with CoC THAs. Patients were evaluated clinically (Harris Hip Score, SF-36) and radiologically at a median of 7.4 years after surgery. Whole blood and urinary cobalt and chromium levels were also assessed. Both types of implants were comparable in terms of clinical and functional results. Ion levels were significantly higher in the MoM group compared with CoC group 7 years after surgery. No correlations were found between metal ion levels and patient demographics, functional and radiological outcomes, and prosthesis features. Patient monitoring is thus advised to establish if prosthesis revision is necessary, especially in the case of MoM THA.
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Affiliation(s)
- Assunta Pozzuoli
- Laboratory of Musculoskeletal Pathology and Oncology, Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
- Correspondence: (A.P.); (E.B.); Tel.: +39-0498213348 (A.P. & E.B.)
| | - Antonio Berizzi
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
| | - Alberto Crimì
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
| | - Elisa Belluzzi
- Laboratory of Musculoskeletal Pathology and Oncology, Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
- Correspondence: (A.P.); (E.B.); Tel.: +39-0498213348 (A.P. & E.B.)
| | - Anna Chiara Frigo
- Epidemiology and Public Health Unit, Department of Cardiac Thoracic Vascular Sciences and Public Health, Biostatistics, University of Padova, Via Loredan 18, 35131 Padova, Italy;
| | - Giorgio De Conti
- Department of Radiology, University Hospital of Padova, Via Giustiniani 2, 35128 Padova, Italy;
| | - Annamaria Nicolli
- Laboratory of Industrial Toxicology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (A.N.); (A.T.)
| | - Andrea Trevisan
- Laboratory of Industrial Toxicology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (A.N.); (A.T.)
| | - Carlo Biz
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
| | - Pietro Ruggieri
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
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Qin HM, Herrera D, Liu DF, Chen CQ, Nersesyan A, Mišík M, Knasmueller S. Genotoxic properties of materials used for endoprostheses: Experimental and human data. Food Chem Toxicol 2020; 145:111707. [PMID: 32889016 DOI: 10.1016/j.fct.2020.111707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/13/2020] [Accepted: 08/22/2020] [Indexed: 12/28/2022]
Abstract
Approximately 2 million endoprostheses are implanted annually and metal ions as well as particles are released into the body from the materials which are used. This review describes the results of studies concerning genotoxic damage caused by artificial joints. DNA damage leads to various adverse long-term health effects in humans including cancer. Experiments with mammalian cells showed that metal ions and particles from orthopedic materials cause DNA damage. Induction of chromosomal aberrations (CA) was found in several in vitro experiments and in studies with rodents with metals from orthopedic materials. Human studies focused mainly on induction of CA (7 studies). Only few investigations (4) concerned sister chromatid exchanges, oxidative DNA damage (2) and micronucleus formation (1). CA are a reliable biomarker for increased cancer risks in humans) and were increased in all studies in patients with artificial joints. No firm conclusion can be drawn at present if the effects in humans are due to oxidative stress and if dissolved metal ions or release particles play a role. Our findings indicate that patients with artificial joints may have increased cancer risks due to damage of the genetic material. Future studies should be performed to identify safe materials and to study the molecular mechanisms in detail.
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Affiliation(s)
- Hong-Min Qin
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Denise Herrera
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Dian-Feng Liu
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Chao-Qian Chen
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Armen Nersesyan
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Miroslav Mišík
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Siegfried Knasmueller
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria.
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Bonner B, Arauz P, Klemt C, Kwon YM. Outcome of Re-Revision Surgery for Adverse Local Tissue Reaction in Metal-on-Polyethylene and Metal-on-Metal Total Hip Arthroplasty. J Arthroplasty 2020; 35:S284-S288. [PMID: 32113811 DOI: 10.1016/j.arth.2020.02.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/27/2020] [Accepted: 02/04/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Adverse local tissue reactions (ALTRs), initially described as a complication of metal-on-metal (MoM) total hip arthroplasty (THA), have also become an important risk factor for implant failure requiring revision surgery in metal-on-polyethylene (MoP) THA due to modular taper corrosion. This study aims to report early complication rates and outcomes as well as potential risk factors for a re-revision. METHODS A total of 252 consecutive THA patients who underwent revision for ALTR were reviewed. There were 40 patients (16%) who underwent a second revision: (1) 26 MoP patients with modular taper corrosion and (2) 14 MoM patients. Patient demographics as well as clinical information were analyzed. Binary logistic regression was used to test for associations between re-revision surgery and clinical parameters. RESULTS The overall complication rate following initial revision for ALTR was 21%. Sixteen percent of these revision patients required a re-revision. The most common indication for re-revision was dislocation (45%). The complication rate was 35% following a re-revision which included dislocation (36%), infection (36%), fracture (14%), and implant loosening (14%). The rate of patients requiring a third revision was 23% with the most common indications being dislocation (33%) and infection (33%) (P = .032). CONCLUSION High rate of early complications (35%) and third revisions (23%) were observed following re-revision of symptomatic ALTR patients with those requiring re-revision associated with extensive intraoperative tissue necrosis. These findings provide clinically useful information that may assist surgeons in clinical decision making and preoperative counseling of both MoM and MoP patients undergoing re-revision surgery for ALTR.
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Affiliation(s)
- Bryant Bonner
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Paul Arauz
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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11
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Ando W, Yasui H, Yamamoto K, Oinuma K, Tokunaga H, Inaba Y, Kobayashi N, Aihara M, Nakanishi R, Ohzono K. A comparison of the effect of large and small metal-on-metal bearings in total hip arthroplasty on metal ion levels and the incidence of pseudotumour. Bone Joint J 2018; 100-B:1018-1024. [DOI: 10.1302/0301-620x.100b8.bjj-2018-0414.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Aims The purpose of this study was to compare two different types of metal-on-metal (MoM) bearing for total hip arthroplasty (THA): one with a large femoral head (38 mm to 52 mm) and the other with a conventional femoral head (28 mm or 32 mm). We compared clinical outcome, blood metal ion levels, and the incidence of pseudotumour in the two groups. Patients and Methods Between December 2009 and December 2011, 62 patients underwent MoM THA with a large femoral head (Magnum group) and 57 patients an MoM THA with a conventional femoral head (conventional group). Clinical outcome was assessed using the Harris Hip score, University of California, Los Angeles (UCLA) activity score and EuroQol-5D (EQ-5D). Blood metal ion levels were measured and MRI scans were analyzed at a minimum of five years postoperatively. Results No acetabular component was implanted with more than 50° of inclination in either group. The Harris Hip Score, UCLA activity score, and EQ-5D improved postoperatively in both groups; no significant clinical differences were noted between the groups. The blood cobalt ion levels in the conventional group continued to rise postoperatively to five years while reaching a plateau at two years postoperatively in the Magnum group. At five years, the mean cobalt ion level of 1.16 μg/l (sd 1.32) in the Magnum group was significantly lower than the 3.77 μg/l (sd 9.80) seen in the conventional group (p = 0.0015). The incidence of moderate to severe pseudotumour was 4.7% in the Magnum group and 20.6% in the conventional group. There were no dislocations in the Magnum group and two in the conventional group. One patient in the Magnum group underwent revision for pseudotumour at 4.7 years postoperatively. Conclusion At five years, a well-positioned large head MoM THA has a significantly lower level of metal ion release and a lower incidence of moderate to severe pseudotumour than a MoM bearing of conventional size. Cite this article: Bone Joint J 2018;100-B:1018–24.
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Affiliation(s)
- W. Ando
- Department of Orthopaedic Surgery, Kansai
Rosai Hospital, Amagasaki, Japan
| | - H. Yasui
- Department of Orthopaedic Surgery, Kansai
Rosai Hospital, Amagasaki, Japan
| | - K. Yamamoto
- Department of Orthopaedic Surgery, Kansai
Rosai Hospital, Amagasaki, Japan
| | - K. Oinuma
- Funabashi Orthopaedic Hospital, Funabashi, Japan
| | - H. Tokunaga
- Department of Orthopaedic Surgery, Kansai
Medical University Medical Center, Moriguchi, Japan
| | - Y. Inaba
- Department of Orthopaedic Surgery, Yokohama
City University, Yokohama, Japan
| | - N. Kobayashi
- Department of Orthopaedic Surgery, Yokohama
City University, Yokohama, Japan
| | - M. Aihara
- Department of Orthopaedic Surgery, Aihara
Hospital, Minoh, Japan
| | - R. Nakanishi
- Department of Orthopaedic Surgery, Showa
University, Fujigaoka Hospital, Yokohama, Japan
| | - K. Ohzono
- Department of Orthopaedic Surgery, Kansai
Rosai Hospital, Amagasaki, Japan
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12
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Matharu GS, Judge A, Eskelinen A, Murray DW, Pandit HG. What is appropriate surveillance for metal-on-metal hip arthroplasty patients? Acta Orthop 2018; 89:29-39. [PMID: 29105547 PMCID: PMC5810829 DOI: 10.1080/17453674.2017.1398011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The unexpected high revision rates of large-diameter (femoral head sizes of 36 mm or greater) metal-on-metal hip arthroplasties (MoMHAs) have led to worldwide regulatory authorities recommending regular surveillance, even for asymptomatic individuals. However, these recommendations are not evidence-based and are very costly. The rapidly evolving evidence base requires an update regarding the investigation and management of MoMHA patients. This article is the first of 2 (the second article in this series will consider the threshold for performing revision, and the outcomes following ARMD revision surgery: Matharu et al., Revision surgery of metal-on-metal hip arthroplasties for adverse reactions to metal debris: A clinical update. Acta Orthop 2018; in press), and considers the various investigative modalities used during surveillance, with specific focus on blood metal ion sampling and cross-sectional imaging. No single investigation can universally be used during MoMHA patient surveillance. Recent studies have now provided important information on interpreting blood metal ions (effective in identifying patients at low risk of problems), clarifying the roles of cross-sectional imaging (reserve combined ultrasound and MARS-MRI for complex cases), and providing parameters to safely exclude many asymptomatic patients from regular surveillance. This information will be useful when designing future surveillance protocols for MoMHA patients.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK;,Correspondence:
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | | | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
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13
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Amanatullah DF, Sucher MG, Bonadurer GF, Pereira GC, Taunton MJ. Metal in Total Hip Arthroplasty: Wear Particles, Biology, and Diagnosis. Orthopedics 2016; 39:371-379. [PMID: 27459144 DOI: 10.3928/01477447-20160719-06] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 06/13/2016] [Indexed: 02/03/2023]
Abstract
Total hip arthroplasty (THA) has been performed for nearly 50 years. Between 2006 and 2012, more than 600,000 metal-on-metal THA procedures were performed in the United States. This article reviews the production of metal wear debris in a metal-on-metal articulation and the interaction of cobalt and chromium ions that ultimately led to a dramatic decline in the use of metal-on-metal THA articulations. Additionally, the article reviews mechanisms of metal wear, the biologic reaction to cobalt and chromium ions, the clinical presentation of failing metal-on-metal articulations, and current diagnostic strategies. Further, the article discusses the use of inflammatory markers, metal ion levels, radiographs, metal artifact reduction sequence magnetic resonance imaging, and ultrasound for failed metal-on-metal THA procedures. When adopting new technologies, orthopedic surgeons must weigh the potential increased benefits against the possibility of new mechanisms of failure. Metal-on-metal bearings are a prime example of the give and take between innovation and clinical results, especially in the setting of an already successful procedure such as THA. [Orthopedics. 2016; 39(6):371-379.].
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14
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Mazoochian F, Schmidutz F, Kiefl J, Fottner A, Michalke B, Schierl R, Thomas’ P, Jansson V. Levels of Cr, Co, Ni and Mo in Erythrocytes, Serum and Urine after Hip Resurfacing Arthroplasty. Acta Chir Belg 2016. [DOI: 10.1080/00015458.2013.11680897] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- F. Mazoochian
- Department of Orthopaedic Surgery,University of Munich (LMU), Campus Grosshadern, Munich, Germany
| | - F. Schmidutz
- Department of Orthopaedic Surgery,University of Munich (LMU), Campus Grosshadern, Munich, Germany
| | - J. Kiefl
- Department of Orthopaedic Surgery,University of Munich (LMU), Campus Grosshadern, Munich, Germany
| | - A. Fottner
- Department of Orthopaedic Surgery,University of Munich (LMU), Campus Grosshadern, Munich, Germany
| | - B. Michalke
- Helmholtz Zentrum München, Institute of Ecological Chemistry, Neuherberg, Germany
| | - R. Schierl
- Department for Occupational,Social and Environmental Medicine, University of Munich (LMU), Munich, Germany
| | - P. Thomas’
- Department of Dermatology and Allergology, University of Munich (LMU), Munich, Germany
| | - V. Jansson
- Department of Orthopaedic Surgery,University of Munich (LMU), Campus Grosshadern, Munich, Germany
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15
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Savarino L, Fotia C, Roncuzzi L, Greco M, Cadossi M, Baldini N, Giannini S. Does chronic raise of metal ion levels induce oxidative DNA damage and hypoxia-like response in patients with metal-on-metal hip resurfacing? J Biomed Mater Res B Appl Biomater 2015; 105:460-466. [PMID: 26477446 DOI: 10.1002/jbm.b.33555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 06/24/2015] [Accepted: 10/03/2015] [Indexed: 02/06/2023]
Abstract
Metal-on-metal hip resurfacing (MOM-HR) represents a viable alternative to traditional arthroplasty. Nevertheless, in MOM coupling both metal nanoparticles and ions are released, whose toxicity remains a matter of concern. We investigated whether 'endogenous' chronic exposure to cobalt and chromium induced a state of oxidative stress, DNA damage and a hypoxia-like response in patients with well-functioning MOM-HR. Twenty-two patients with unilateral MOM-HR were recruited at long-term. Twenty-one osteoarthritic subjects were enrolled for comparison. Serum ion levels were measured and correlated with 8-hydroxydeoxyguanosine and circulating-free-DNA, as markers of oxidative DNA damage. Moreover, the hypoxia-inducible factor-1α, marker of hypoxic state, was evaluated. Ion concentrations were found to be 5-to-15 times higher in MOM-HR patients than in presurgery subjects (p < 0.001); circulating-free-DNA, 8-hydroxydeoxyguanosine, and hypoxia-inducible factor-1α levels were not significantly different between groups and did not correlate with ion levels. Analyzing the results according to gender, MOM-HR males had higher 8-hydroxydeoxyguanosine levels (p = 0.01) compared with MOM-HR females. Similarly, circulating-free-DNA values were higher in males than females, even if this difference did not reach statistical significance. This research is the first that attempted to investigate the long-term effects of ion dissemination in subjects with well-fixed MOM implants. A significant correlation between biomarkers increase and ion levels was not demonstrated. Nevertheless, both circulating-free-DNA and 8-hydroxydeoxyguanosine showed a tendency to increase in MOM-HR males. Further studies with a larger sample size should be performed to detect the clinical relevance of biomarkers increase especially in younger subjects, where a chronic moderately elevated exposure has to be faced. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 460-466, 2017.
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Affiliation(s)
- Lucia Savarino
- Laboratory for Orthopaedic Pathophysiology and Regenerative Medicine, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Caterina Fotia
- Laboratory for Orthopaedic Pathophysiology and Regenerative Medicine, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Laura Roncuzzi
- Laboratory for Orthopaedic Pathophysiology and Regenerative Medicine, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Michelina Greco
- Laboratory for Orthopaedic Pathophysiology and Regenerative Medicine, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Matteo Cadossi
- Department I of Orthopaedics and Traumatology, Rizzoli Orthopedic Institute, Bologna, Italy
| | - Nicola Baldini
- Laboratory for Orthopaedic Pathophysiology and Regenerative Medicine, Rizzoli Orthopaedic Institute, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, Bologna University, Bologna, Italy
| | - Sandro Giannini
- Department I of Orthopaedics and Traumatology, Rizzoli Orthopedic Institute, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, Bologna University, Bologna, Italy
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16
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Ando W, Yamamoto K, Atsumi T, Tamaoki S, Oinuma K, Shiratsuchi H, Tokunaga H, Inaba Y, Kobayashi N, Aihara M, Ohzono K. Comparison between component designs with different femoral head size in metal-on-metal total hip arthroplasty; multicenter randomized prospective study. J Orthop 2015; 12:228-36. [PMID: 26566324 DOI: 10.1016/j.jor.2015.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 05/24/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUNDS/AIMS We prospectively studied 78 prostheses with conventional femoral head and 86 prostheses with large head (Magnum) of metal-on-metal total hip arthroplasty (MoM THA) with two years follow-up. METHODS Clinical outcomes and blood metal ion were evaluated. RESULTS There were no significant differences of clinical outcomes between groups. 1.17 ± 1.01 μg/L of blood cobalt ion in Magnum was significantly lower than 1.99 ± 2.34 μg/L in conventional group. No dislocation was observed in Magnum while one dislocation in conventional group. MoM THA with large head is useful if the implants are positioned in appropriate alignment, however longer follow-up will be necessary. CLINICAL TRIAL REGISTRATION NCT01010763 (registered on ClinicalTrials.gov).
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Affiliation(s)
- Wataru Ando
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, 660-8511, Japan
| | - Kengo Yamamoto
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, 660-8511, Japan
| | - Takashi Atsumi
- Department of Orthopaedic Surgery, Showa University, Fujigaoka Hospital, Yokohama, Kanagawa, 227-8501, Japan
| | - Satoshi Tamaoki
- Department of Orthopaedic Surgery, Showa University, Fujigaoka Hospital, Yokohama, Kanagawa, 227-8501, Japan
| | - Kazuhiro Oinuma
- Funabashi Orthopaedic Hospital, Funabashi, Chiba, 274-0822, Japan
| | | | - Hirohiko Tokunaga
- Department of Orthopaedic Surgery, Kansai Medical University Takii Hospital, Moriguchi, Osaka, 570-8507, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Kanagawa, 236-0004, Japan
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Kanagawa, 236-0004, Japan
| | - Masaharu Aihara
- Department of Orthopaedic Surgery, Aihara Hospital, Mino, Osaka, 562-0004, Japan
| | - Kenji Ohzono
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, 660-8511, Japan
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17
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Influence of implant design on blood metal ion concentrations in metal-on-metal total hip replacement patients. INTERNATIONAL ORTHOPAEDICS 2015; 39:1803-11. [PMID: 25655902 DOI: 10.1007/s00264-014-2644-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 12/14/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Most factors considered to affect blood metal ions following metal-on-metal hip replacement are based on hip resurfacing patients. The study aims were to determine which factors affect blood metal ion concentrations following metal-on-metal total hip replacement (MoM THR). METHODS All unilateral MoM THR patients at one centre with whole-blood cobalt (Co) and chromium (Cr) concentrations measured up to May 2013 were included. Blood sampling was at a mean of 4.5 years (range 1.1-11.8 years) postoperatively. RESULTS Of 496 patients (mean age 59.1 years; 52.8% male), blood metal ions >7 μg/l were observed in 9.7% (n = 48). Large femoral head sizes (≥38 mm) had significantly higher (p < 0.0001) blood metal ions than smaller sizes (28/36 mm). Corail-Pinnacle implants produced significantly lower blood metal ions compared to other implant designs (p < 0.01 Co and Cr). Univariate linear regression demonstrated the only significant predictors of both blood Co and Cr concentrations were femoral head size (R(2) = 8.6% Co and R(2) = 3.3% Cr, both p < 0.0001) and implant design (R(2) = 8.8%, p = 0.005 Co and R(2) = 5.1%, p = 0.003 Cr). When the three THR implant design groups (Corail-Pinnacle, Synergy, Other) were analysed separately, femoral head size no longer significantly affected blood metal ions in any of the three implant design groups. CONCLUSIONS Implant design was the most important factor affecting blood metal ion concentrations. We recommend the regularity of follow-up be tailored to survival rates of various MoM THR designs rather than according to femoral head size.
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18
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What are the predictors and prevalence of pseudotumor and elevated metal ions after large-diameter metal-on-metal THA? Clin Orthop Relat Res 2015; 473:477-84. [PMID: 25085361 PMCID: PMC4294930 DOI: 10.1007/s11999-014-3824-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Soft tissue masses, or "pseudotumors," around metal-on-metal total hip arthroplasty (MoM THA) have been reported frequently; however, their prevalence remains unknown. Several risk factors, including elevated metal ion levels, have been associated with the presence of pseudotumor, although this remains controversial. QUESTIONS/PURPOSES The goals of this study were to (1) determine the prevalence of pseudotumors after large-diameter head MoM THA; (2) identify risk factors associated with pseudotumor formation and elevated metal ion levels; and (3) determine the early failure rate of large-diameter MoM THA. METHODS Between December 2005 and November 2012, 258 hips (215 patients) underwent large-diameter head primary MoM THA at our institution. Clinical followup was obtained in 235 hips (91%). Using an inclusion criteria of a minimum followup of 1 year, a subset of 191 hips (mean followup, 4 years; range, 1-7 years) was recruited for high-resolution ultrasound screening for the presence of pseudotumor. Whole blood cobalt and chromium ion levels, UCLA activity level, WOMAC score, patient demographics as well as surgical, implant, and radiographic data were collected. Bivariate correlations and multivariate log-linear regression models were used to compare the presence of pseudotumor and elevated metal ions with all other factors. RESULTS Ultrasound detected a solid, cystic, or mixed mass in 20% hips (38 of 191). No correlation was found between the presence of pseudotumor and any risk factor that we examined. After controlling for confounding variables, elevated cobalt ions were correlated (p<0.001, R=0.50, R2=0.25) with smaller femoral head size, the presence of bilateral MoM THA, and female sex. Elevated chromium ions were correlated (p<0.001, R=0.59, R2=0.34) with smaller femoral head size, presence of bilateral MoM THA, and lower body mass index. The overall survival of MoM THA was 96% at a mean followup of 4.5 years (range, 2-8 years). CONCLUSIONS With the numbers available, we found no associations between the presence of pseudotumor and the potential risk factors we analyzed, including elevated metal ion levels. Further work is needed to explain why larger femoral head sizes resulted in lower metal ion levels despite being associated with higher early failure rates in joint registry data. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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19
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Elkins JM, Callaghan JJ, Brown TD. The 2014 Frank Stinchfield Award: The 'landing zone' for wear and stability in total hip arthroplasty is smaller than we thought: a computational analysis. Clin Orthop Relat Res 2015; 473:441-52. [PMID: 25091222 PMCID: PMC4294904 DOI: 10.1007/s11999-014-3818-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Positioning of total hip bearings involves tradeoffs, because cup orientations most favorable in terms of stability are not necessarily ideal in terms of reduction of contact stress and wear potential. Previous studies and models have not addressed these potentially competing considerations for optimal total hip arthroplasty (THA) function. QUESTIONS/PURPOSES We therefore asked if component positioning in total hips could be addressed in terms of balancing bearing surface wear and stability. Specifically, we sought to identify acetabular component inclination and anteversion orientation, which simultaneously resulted in minimal wear while maximizing construct stability, for several permutations of femoral head diameter and femoral stem anteversion. METHODS A validated metal-on-metal THA finite element (FE) model was used in this investigation. Five dislocation-prone motions as well as gait were considered as were permutations of femoral anteversion (0°-30°), femoral head diameter (32-48 mm), cup inclination (25°-75°), and cup anteversion (0°-50°), resulting in 4320 distinct FE simulations. A novel metric was developed to identify a range of favorable cup orientations (so-called "landing zone") by considering both surface wear and component stability. RESULTS When considering both wear and stability with equal weight, ideal cup position was more restrictive than the historically defined safe zone and was substantially more sensitive to cup anteversion than to inclination. Ideal acetabular positioning varied with both femoral head diameter and femoral version. In general, ideal cup inclination decreased with increased head diameter (approximately 0.5° per millimeter increase in head diameter). Additionally, ideal inclination increased with increased values of femoral anteversion (approximately 0.3° per degree increase in stem anteversion). Conversely, ideal cup anteversion increased with increased femoral head diameter (0.3° per millimeter increase) and decreased with increased femoral stem anteversion (approximately 0.3° per degree increase). Regressions demonstrated strong correlations between optimal cup inclination versus head diameter (Pearson's r=-0.88), between optimal cup inclination versus femoral anteversion (r=0.96), between optimal cup anteversion versus head diameter (r=0.99), and between optimal cup anteversion and femoral anteversion (r=-0.98). For a 36-mm cup with a 20° anteverted stem, the ideal cup orientation was 46°±12° inclination and 15°±4° anteversion. CONCLUSIONS The range of cup orientations that maximized stability and minimized wear (so-called "landing zone") was substantially smaller than historical guidelines and specifically did not increase with increased head size, challenging the presumption that larger heads are more forgiving. In particular, when the cup is oriented to improve not only stability, but also wear in the model, there was little or no added stability achieved by the use of larger femoral heads. Additionally, ideal cup positioning was more sensitive to cup anteversion than to inclination. CLINICAL RELEVANCE Positioning THA bearings involves tradeoffs regarding stability and long-term bearing wear. Cup positions most favorable to minimization of wear such as low inclination and elevated anteversion were detrimental in terms of construct stability. Orientations were identified that best balanced the competing considerations of wear and stability.
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Affiliation(s)
- Jacob M Elkins
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA,
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20
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Matusiewicz H. Potential release of in vivo trace metals from metallic medical implants in the human body: from ions to nanoparticles--a systematic analytical review. Acta Biomater 2014; 10:2379-403. [PMID: 24565531 DOI: 10.1016/j.actbio.2014.02.027] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/04/2013] [Accepted: 02/13/2014] [Indexed: 02/06/2023]
Abstract
Metal ion release from metallic materials, e.g. metallic alloys and pure metals, implanted into the human body in dental and orthopedic surgery is becoming a major cause for concern. This review briefly provides an overview of both metallic alloys and pure metals used in implant materials in dental and orthopedic surgery. Additionally, a short section is dedicated to important biomaterials and their corrosive behavior in both real solutions and various types of media that model human biological fluids and tissues. The present review gives an overview of analytical methods, techniques and different approaches applied to the measurement of in vivo trace metals released into body fluids and tissues from patients carrying metal-on-metal prostheses and metal dental implants. Reference levels of ion concentrations in body fluids and tissues that have been determined by a host of studies are compiled, reviewed and presented in this paper. Finally, a collection of published clinical data on in vivo released trace metals from metallic medical implants is included.
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21
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Smith J, Lee D, Bali K, Railton P, Kinniburgh D, Faris P, Marshall D, Burkart B, Powell J. Does bearing size influence metal ion levels in large-head metal-on-metal total hip arthroplasty? A comparison of three total hip systems. J Orthop Surg Res 2014; 9:3. [PMID: 24472283 PMCID: PMC3916311 DOI: 10.1186/1749-799x-9-3] [Citation(s) in RCA: 18] [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: 08/29/2013] [Accepted: 01/21/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The purpose of the study was twofold: first, to determine whether there is a statistically significant difference in the metal ion levels among three different large-head metal-on-metal (MOM) total hip systems. The second objective was to assess whether position of the implanted prostheses, patient demographics or factors such as activity levels influence overall blood metal ion levels and whether there is a difference in the functional outcomes between the systems. METHODS In a cross-sectional cohort study, three different metal-on-metal total hip systems were assessed: two monoblock heads, the Durom socket (Zimmer, Warsaw, IN, USA) and the Birmingham socket (Smith and Nephew, Memphis, TN, USA), and one modular metal-on-metal total hip system (Pinnacle, Depuy Orthopedics, Warsaw, IN, USA). Fifty-four patients were recruited, with a mean age of 59.7 years and a mean follow-up time of 41 months (12 to 60). Patients were evaluated clinically, radiologically and biochemically. Statistical analysis was performed on all collected data to assess any differences between the three groups in terms of overall blood metal ion levels and also to identify whether there was any other factor within the group demographics and outcomes that could influence the mean levels of Co and Cr. RESULTS Although the functional outcome scores were similar in all three groups, the blood metal ion levels in the larger monoblock large heads (Durom, Birmingham sockets) were significantly raised compared with those of the Pinnacle group. In addition, the metal ion levels were not found to have a statistically significant relationship to the anteversion or abduction angles as measured on the radiographs. CONCLUSIONS When considering a MOM THR, the use of a monoblock large-head system leads to higher elevations in whole blood metal ions and offers no advantage over a smaller head modular system.
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Affiliation(s)
| | | | | | | | | | | | | | | | - James Powell
- Orthopaedic Trauma and Lower Extremity Reconstruction, University of Calgary, #0444 3134 Hospital Drive NW Calgary AB T2N 5A1, Canada.
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22
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Emmanuel AR, Bergin KM, Kelly GE, McCoy GF, Wozniak AP, Quinlan JF. The effect of acetabular inclination on metal ion levels following metal-on-metal hip arthroplasty. J Arthroplasty 2014; 29:186-91. [PMID: 23759116 DOI: 10.1016/j.arth.2013.04.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 04/15/2013] [Indexed: 02/01/2023] Open
Abstract
Acetabular inclination angles have been suggested as a principal determinant of circulating metal ion levels in metal-on-metal hip arthroplasties. We aimed to determine whether inclination angle correlates with ion levels in arthroplasties using the Articular Surface Replacement (ASR) system. Patients undergoing ASR arthroplasties had blood metal ion levels and radiograph analysis performed a mean of 3.2 years after surgery. Inclination angle showed only a weak correlation with cobalt (r=0.21) and chromium (r=0.15) levels. The correlation between inclination angle and cobalt levels was significant only with small femoral components, although it was still weak. Multiple regression showed a complex interaction of factors influencing ion levels but inclination angle accounted for little of this variation. We conclude that the acetabular inclination angle is not a meaningful determinant of metal ion levels in ASR arthroplasties.
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Affiliation(s)
- Andrew R Emmanuel
- Lourdes Orthopaedic Hospital, Kilcreene, Kilkenny, Republic of Ireland
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23
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Jantzen C, Jørgensen HL, Duus BR, Sporring SL, Lauritzen JB. Chromium and cobalt ion concentrations in blood and serum following various types of metal-on-metal hip arthroplasties: a literature overview. Acta Orthop 2013; 84:229-36. [PMID: 23594249 PMCID: PMC3715816 DOI: 10.3109/17453674.2013.792034] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [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 Widely different metal ion concentrations in blood and serum have been reported with metal-on-metal (MoM) implants. We reviewed the literature on blood and serum ion concentrations of chromium (Cr) and cobalt (Co) following various MoM hip arthroplasties. METHODS Studies were searched for in the Medline database, Embase, and the Cochrane Database of Systematic Reviews. Highest mean or median ion concentrations of Cr and Co after a minimum of 1 year of follow-up were extracted and grouped according to sample- and articulation type, and average values were calculated. RESULTS 43 studies were included and 16 different MoM implants were identified. For the different types of bearings, average ion concentrations and range were calculated from the mean or median ion concentration. The average Cr concentration ranged between 0.5 and 2.5 μg/L in blood and between 0.8 and 5.1 μg/L in serum. For Co, the range was 0.7-3.4 μg/L in blood and 0.3-7.5 μg/L in serum. INTERPRETATION When the average blood ion concentrations calculated for the different implants, together with the concentrations measured in the individual studies, were compared with the upper acceptable limit for Cr and Co in blood, no clear pattern was recognized. Furthermore, we were unable to detect any clear difference in ion concentrations between different types of implants (THA and resurfacing).
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Affiliation(s)
| | - Henrik L Jørgensen
- Clinical Biochemistry, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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24
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25
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Georgiou C, Evangelou K, Theodorou E, Provatidis C, Megas P. Does Choice of Head Size and Neck Geometry Affect Stem Migration in Modular Large-Diameter Metal-on-Metal Total Hip Arthroplasty? A Preliminary Analysis. Open Orthop J 2012; 6:593-600. [PMID: 23284597 PMCID: PMC3529402 DOI: 10.2174/1874325001206010593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 11/07/2012] [Accepted: 11/07/2012] [Indexed: 11/25/2022] Open
Abstract
Due to their theoretical advantages, hip systems combining modular necks and large diameter femoral heads have gradually gained popularity. However, among others, concerns regarding changes in the load transfer patterns were raised. Recent stress analyses have indeed shown that the use of modular necks and big femoral heads causes significant changes in the strain distribution along the femur. Our original hypothesis was that these changes may affect early distal migration of a modular stem. We examined the effect of head diameter and neck geometry on migration at two years of follow-up in a case series of 116 patients (125 hips), who have undergone primary Metal-on-Metal total hip arthroplasty with the modular grit-blasted Profemur®E stem combined with large-diameter heads (>36 mm). We found that choice of neck geometry and head diameter has no effect on stem migration. A multivariate regression analysis including the potential confounding variables of the body mass index, bone quality, canal fill and stem positioning revealed only a negative correlation between subsidence and canal fill in midstem area. Statistical analysis, despite its limitations, did not confirm our hypothesis that choice of neck geometry and/or head diameter affects early distal migration of a modular stem. However, the importance of correct stem sizing was revealed.
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Affiliation(s)
- Cs Georgiou
- Department of Orthopaedics and Traumatology, University Hospital of Patras, Greece
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26
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Elkins JM, Kruger KM, Pedersen DR, Callaghan JJ, Brown TD. Edge-loading severity as a function of cup lip radius in metal-on-metal total hips--a finite element analysis. J Orthop Res 2012; 30:169-77. [PMID: 21812025 PMCID: PMC5160130 DOI: 10.1002/jor.21524] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 07/14/2011] [Indexed: 02/04/2023]
Abstract
While favorable tribological properties and allowance for larger femoral head sizes have made metal-on-metal (MoM) bearings an increasingly popular choice for total hip arthroplasty, concerns have mounted regarding adverse reactions to metal wear debris and ions. MoM cups differ from conventional polyethylene cups in terms of edge profile design and reductions from full hemisphericity, suggesting differences in loading at or near the cup edge, especially during subluxation events. Finite element analysis was used to investigate the effects of cup orientation and lip edge curvature on damage propensity for edge or near-edge loading during subluxation. Increased cup lip radius (resulting in reduced articular arc) had a detrimental effect upon subluxation-free hip range of motion and upon dislocation resistance. Contact stresses near the cup edge demonstrated complex relationships between edge radius and cup orientation, with peak stresses being influenced by both variables. The tendency for scraping wear at the egress site demonstrated similarly complex dependencies. These data indicate that acetabular cup design is an important determinant of edge and near-edge loading damage propensity.
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Affiliation(s)
- Jacob M. Elkins
- Department of Orthopaedics and Rehabilitation, University of Iowa
- Department of Biomedical Engineering, University of Iowa
| | - Karen M. Kruger
- Department of Orthopaedics and Rehabilitation, University of Iowa
- Department of Biomedical Engineering, University of Iowa
| | - Douglas R. Pedersen
- Department of Orthopaedics and Rehabilitation, University of Iowa
- Department of Biomedical Engineering, University of Iowa
| | - John J. Callaghan
- Department of Orthopaedics and Rehabilitation, University of Iowa
- Department of Biomedical Engineering, University of Iowa
- Iowa City Veterans Administration Medical Center
| | - Thomas D. Brown
- Department of Orthopaedics and Rehabilitation, University of Iowa
- Department of Biomedical Engineering, University of Iowa
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