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Fu L, Xie H, Huang J, Chen X, Chen L. Determination of ultra-trace levels of titanium in human serum using inductively coupled plasma tandem mass spectrometry based on O 2/H 2 reaction gas. Anal Chim Acta 2021; 1165:338564. [PMID: 33975704 DOI: 10.1016/j.aca.2021.338564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 11/15/2022]
Abstract
This study proposes a new strategy to determine ultra-trace Ti in human serum using inductively coupled plasma tandem mass spectrometry (ICP-MS/MS). The human serum samples were diluted with 1% (v/v) HNO3, followed by the determination of ultra-trace Ti using ICP-MS/MS. In the MS/MS mode, a small amount of H2 was mixed with O2 (the reaction gas) in a collision reaction cell (CRC) to form an O2/H2 reaction mixture, and then, the conversion of Ti+ to TiO+ was determined by the O2 mass shift method. High concentrations of Ca, S, and P in human serum were ionized in plasma, and the formed Ca+, SO+, and PO + reacted with O2 in CRC to form CaO+, SO2+, and PO2+ to interfere with the determination of TiO+. We employed the mass shift reaction of H2 and oxide ions to eliminate this interference. This method was evaluated using the human serum sample spike recovery experiment and comparative analysis by sector field (SF)-ICP-MS. The results showed that using reaction gas mixture O2/H2 reduced the background equivalent concentration (BEC) of Ti and improved sensitivity. The values determined by this method were consistent with the SF-ICP-MS values, which confirmed its accuracy and reliability. The limit of detection (LOD) of Ti was 0.78-7.20 ng L-1, the recovery was 96.0%-104%, and the relative standard deviation (RSD) was 2.0%-4.2%. This method has solved the problem that the determination of ultra-trace Ti in human serum cannot be accurately determined using O2 reaction mode. It realizes the interference-free and highly sensitive determination of the ultra-trace Ti in samples with high levels of Ca, S, and P and provides a new technique for high-throughput and accurate determination of ultra-trace Ti in human serum.
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Affiliation(s)
- Liang Fu
- College of Materials Science and Engineering, Chongqing University, Chognqing, 400045, PR China.
| | - Hualin Xie
- College of Materials Science and Engineering, Yangtze Normal University, Fuling, 408100, PR China
| | - Jianhua Huang
- Hunan Academy of Chinese Medicine, Hunan University of Chinese Medicine, Changsha, 410013, PR China
| | - Xianhua Chen
- College of Materials Science and Engineering, Chongqing University, Chognqing, 400045, PR China.
| | - Lin Chen
- Hunan Academy of Chinese Medicine, Hunan University of Chinese Medicine, Changsha, 410013, PR China
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2
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Fokter SK, Zajc J, Merc M. Interchangeable neck failures of bi-modular femoral stems in primary total hip arthroplasty cannot be predicted from serum trace element analysis. INTERNATIONAL ORTHOPAEDICS 2020; 45:877-881. [PMID: 32935199 DOI: 10.1007/s00264-020-04812-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Revision of a well-fixed stem due to unexpected modular neck fracture is a catastrophe for the patient and a challenge for the surgeon. This study aimed to test the possibility of predicting interchangeable neck fracture from serum levels of the stem/neck alloy-consisting metals. MATERIALS AND METHODS Nineteen patients at high risk for interchangeable neck fracture were randomly selected out of a cohort of 680 bimodular stems made from Ti6Al4V alloy. Serum levels of titanium, aluminium and vanadium were determined. Nine age- and gender-matched patients were used as controls. RESULTS Mean serum levels of Ti were 6.04 ± 2.52 μg/L, of Al 3.89 ± 1.68 μg/L and of V 0.07 ± 0.04 μg/L in the high-risk group, and 8.22 ± 4.74 μg/L, 4.99 ± 3.98 μg/L and 0.27 ± 0.44 μg/L in the low-risk group, respectively. No statistically significant differences were found between the groups. DISCUSSION Interchangeable neck fracture of bimodular femoral stems cannot be predicted from serum trace element analysis.
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Affiliation(s)
- Samo K Fokter
- Department for Orthopaedic Surgery, University Medical Centre Maribor, 5 Ljubljanska Street, SLO-2000, Maribor, Slovenia.
| | - Jan Zajc
- Faculty of Medicine, University of Maribor, 8 Taborska Street, SLO-2000 Maribor, Slovenia
| | - Matjaž Merc
- Department for Orthopaedic Surgery, University Medical Centre Maribor, 5 Ljubljanska Street, SLO-2000, Maribor, Slovenia
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Yao JJ, Lewallen EA, Thaler R, Dudakovic A, Wermers M, Day P, Eckdahl S, Jannetto P, Bornhorst JA, Larson AN, Abdel MP, Lewallen DG, van Wijnen AJ. Challenges in the Measurement and Interpretation of Serum Titanium Concentrations. Biol Trace Elem Res 2020; 196:20-26. [PMID: 31696354 DOI: 10.1007/s12011-019-01891-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/03/2019] [Indexed: 11/25/2022]
Abstract
The measurement of circulating metal ion levels in total hip arthroplasty patients continues to be an area of clinical interest. National regulatory agencies have recommended measurement of circulating cobalt and chromium concentrations in metal-on-metal bearing symptomatic total hip arthroplasty patients. However, the clinical utility of serum titanium (Ti) measurements is less understood due to wide variations in reported values and methodology. Fine-scale instrumentation for detecting in situ Ti levels continues to improve and has transitioned from graphite furnace atomic absorption spectroscopy to inductively coupled plasma optical emission spectrometry or inductively coupled plasma mass spectrometry. Additionally, analytical interferences, variable sample types, and non-standardized sample collection methods complicate Ti measurement and underlie the wide variation in reported levels. Normal reference ranges and pathologic ranges for Ti levels remain to be established quantitatively. However, before these ranges can be recognized and implemented, methodological standardization is necessary. This paper aims to provide background and recommendations regarding the complexities of measurement and interpretation of circulating Ti levels in total hip arthroplasty patients.
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Affiliation(s)
- Jie J Yao
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Eric A Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
- Department of Biological Sciences, Hampton University, Hampton, VA, USA
| | - Roman Thaler
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
| | - Amel Dudakovic
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Michelle Wermers
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Patrick Day
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Steve Eckdahl
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Paul Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Joshua A Bornhorst
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
| | - David G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
| | - Andre J van Wijnen
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA.
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA.
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Hall DJ, Pourzal R, Jacobs JJ. What Surgeons Need to Know About Adverse Local Tissue Reaction in Total Hip Arthroplasty. J Arthroplasty 2020; 35:S55-S59. [PMID: 32005621 PMCID: PMC7239747 DOI: 10.1016/j.arth.2020.01.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 02/01/2023] Open
Abstract
Adverse local tissue reactions (ALTRs) were first associated with patients with failed metal-on-metal surface replacements and total hip arthroplasty (THA). However, an increasing number of cases of ALTR in metal-on-polyethylene (MOP) THA patients is being reported. Clinically, ALTR appears as benign, aseptic masses or bursae in the periprosthetic tissues. Histopathologically, ALTRs are distinguished by an intense lymphocyte infiltrate, destruction of the synovial surfaces, widespread necrosis, and fibrin exudate. Tribocorrosion of modular junctions appears to be the cause of ALTR in MOP patients. The various tribocorrosion damage modes occurring at modular junctions produce metal ions and a diversity of particulates in relation to size, chemical composition, and structure. The mechanisms by which these various products of tribocorrosion lead to ALTR are still a matter of considerable research. This review clarifies what constitutes ALTR, its relationship to implant factors, and highlights current methods for diagnosis and management of patients with ALTR in the setting of MOP THA.
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Affiliation(s)
- Deborah J Hall
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Robin Pourzal
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Joshua J Jacobs
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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Swiatkowska I, Martin N, Hart AJ. Blood titanium level as a biomarker of orthopaedic implant wear. J Trace Elem Med Biol 2019; 53:120-128. [PMID: 30910194 DOI: 10.1016/j.jtemb.2019.02.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/18/2019] [Accepted: 02/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Joint replacement implants are usually manufactured from cobalt-chromium or titanium alloys. After the device is implanted, wear and corrosion generate metal particles and ions, which are released into local tissue and blood. The metal debris can cause a range of adverse local and systemic effects in patients. RESEARCH PROBLEM In the case of cobalt and chromium, a blood level exceeding 7 μg L-1 indicates potential for local toxicity, and a failing implant. It has been repeatedly suggested in the literature that measurement of titanium could also be used to assess implant function. Despite an increasing interest in this biomarker, and growing use of titanium in orthopaedics, it is unclear what blood concentrations should raise concerns. This is partly due to the technical challenges involved in the measurement of titanium in biological samples. AIM This Review summarises blood/serum titanium levels associated with well-functioning and malfunctioning prostheses, so that the prospects of using titanium measurements to gain insights into implant performance can be evaluated. CONCLUSION Due to inter-laboratory analytical differences, reliable conclusions regarding "normal" and "abnormal" titanium levels in patients with orthopaedic implants are difficult to draw. Diagnosis of symptomatic patients should be based on radiographic evidence combined with blood/serum metal levels.
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Affiliation(s)
- Ilona Swiatkowska
- Institute of Orthopaedics and Musculoskeletal Science, University College London, HA7 4LP, Stanmore, UK.
| | - Nicholas Martin
- Trace Element Laboratory, Clinical Biochemistry, Charing Cross Hospital, W6 8RF, London, UK
| | - Alister J Hart
- Institute of Orthopaedics and Musculoskeletal Science, University College London, HA7 4LP, Stanmore, UK; Royal National Orthopaedic Hospital, Stanmore, HA7 4LP, UK
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Vendittoli PA, Massé V, Kiss MO, Lusignan D, Lavigne M. Modular junction may be more problematic than bearing wear in metal-on-metal total hip arthroplasty. Hip Int 2019; 29:262-269. [PMID: 30378457 DOI: 10.1177/1120700018808696] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION In total hip arthroplasty (THA), local adverse reaction to metal debris (ARMD) may be caused by abnormal metal ion release from a metal-on-metal (MoM) bearing, or by wear and corrosion of the implant's modular junction. The aim of this study was to compare ion levels and rate of ARMD between patients sharing the same MoM bearing but 1 group having monoblock stems versus another having modular stems. MATERIALS AND METHODS Whole blood cobalt (Co) and chromium (Cr) ion concentrations, ARMD rate, revision rate, and function measured by UCLA and WOMAC scores were compared between groups. RESULTS ARMD rate was significantly higher in the modular group (46%) compared with the monoblock group (16%, p = 0.031). Revision for ARMD was performed at 52.8 ± 8.1 months in the modular group versus 98.2 ± 15.5 months after primary THA in the monoblock group. ARMD originated from wear and corrosion of the junction between stem and femoral head adapter sleeve in all monoblock cases, and the junction between stem and modular neck in all the modular ones. Cr and Co ions levels were significantly higher in the modular stem group ( p < 0.001 for both). CONCLUSIONS Although both groups had MoM bearings, corrosion at stem/neck or neck/head junctions combining dissimilar metal (Ti and Cr-Co) was seen as the source of excess metal ions release leading to ARMD. Poor performance of the modular junction may be more deleterious than wear of the bearing. To avoid such complications, THA femoral stem modular junctions should be eliminated (return to a full monoblock implant) or have improved junction design.
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Affiliation(s)
- Pascal-André Vendittoli
- Department of Surgery, University of Montreal, Hospital Maisonneuve-Rosemont, Montreal, Canada
| | - Vincent Massé
- Department of Surgery, University of Montreal, Hospital Maisonneuve-Rosemont, Montreal, Canada
| | - Marc-Olivier Kiss
- Department of Surgery, University of Montreal, Hospital Maisonneuve-Rosemont, Montreal, Canada
| | - Daniel Lusignan
- Department of Surgery, University of Montreal, Hospital Maisonneuve-Rosemont, Montreal, Canada
| | - Martin Lavigne
- Department of Surgery, University of Montreal, Hospital Maisonneuve-Rosemont, Montreal, Canada
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Reiner T, Bader N, Panzram B, Bülhoff M, Omlor G, Kretzer JP, Raiss P, Zeifang F. In vivo blood metal ion levels in patients after total shoulder arthroplasty. J Shoulder Elbow Surg 2019; 28:539-546. [PMID: 30518478 DOI: 10.1016/j.jse.2018.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/17/2018] [Accepted: 08/19/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Products from metal wear have been identified as a potential cause of adverse local tissue reactions and implant failure in total hip arthroplasty. However, the role of metal ion exposure in patients after total shoulder replacement is unclear. The objective of the present study was to determine in vivo blood metal ion levels of cobalt, chromium, and titanium in patients after anatomic total shoulder arthroplasty (TSA) or reverse TSA. METHODS A consecutive series of patients after anatomic TSA or reverse TSA was evaluated retrospectively. After exclusion of patients with additional metal implants, 40 patients with unilateral anatomic TSA (n = 20) or reverse TSA (n = 20) were available for whole-blood metal ion analysis at a mean follow-up of 28 ± 9.6 months. Twenty-three healthy individuals without metal implants served as a control group. RESULTS Mean cobalt ion concentrations were 0.18 µg/L (range, 0.1-0.66 µg/L), 0.15 µg/L (range, 0.03-0.48 µg/L), and 0.11 µg/L (range, 0.03-0.19 µg/L), mean chromium ion levels were 0.48 µg/L (range, 0.17-2.41 µg/L), 0.31 µg/L (range, 0.09-1.26 µg/L), and 0.14 µg/L (range, 0.04-0.99 µg/L), and mean titanium ion concentrations were 1.31 µg/L (range, 0.75-4.52 µg/L), 0.84 µg/L (range, 0.1-1.64 µg/L), and 0.62 µg/L (range, 0.32-2.14 µg/L) in the reverse TSA group, the anatomic TSA group, and the control group, respectively. CONCLUSIONS TSA resulted in elevated metal ion levels compared with healthy controls, although overall metal ion concentrations measured in this study were relatively low. The role of local metal ion exposure in patients with total shoulder replacements should be further investigated.
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Affiliation(s)
- Tobias Reiner
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.
| | - Nina Bader
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Panzram
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Bülhoff
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Georg Omlor
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan P Kretzer
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Patric Raiss
- OCM (Orthopädische Chirurgie München) Clinic for Orthopedic Surgery, Munich, Germany
| | - Felix Zeifang
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
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8
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Ferko MA, Catelas I. Effects of metal ions on caspase-1 activation and interleukin-1β release in murine bone marrow-derived macrophages. PLoS One 2018; 13:e0199936. [PMID: 30138321 PMCID: PMC6107125 DOI: 10.1371/journal.pone.0199936] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/15/2018] [Indexed: 02/07/2023] Open
Abstract
Ions released from metal implants have been associated with adverse tissue reactions and are therefore a major concern. Studies with macrophages have shown that cobalt, chromium, and nickel ions can activate the NLRP3 inflammasome, a multiprotein complex responsible for the activation of caspase-1 (a proteolytic enzyme converting pro-interleukin [IL]-1β to mature IL-1β). However, the mechanism(s) of inflammasome activation by metal ions remain largely unknown. The objectives of the present study were to determine if, in macrophages: 1. caspase-1 activation and IL-1β release induced by metal ions are oxidative stress-dependent; and 2. IL-1β release induced by metal ions is NF-κB signaling pathway-dependent. Lipopolysaccharide (LPS)-primed murine bone marrow-derived macrophages (BMDM) were exposed to Co2+ (6-48 ppm), Cr3+ (100-500 ppm), or Ni2+ (12-96 ppm), in the presence or absence of a caspase-1 inhibitor (Z-WEHD-FMK), an antioxidant (L-ascorbic acid [L-AA]), or an NF-κB inhibitor (JSH-23). Culture supernatants were analyzed for caspase-1 by western blotting and/or IL-1β release by ELISA. Immunoblotting revealed the presence of caspase-1 (p20 subunit) in supernatants of BMDM incubated with Cr3+, but not with Ni2+ or Co2+. When L-AA (2 mM) was present with Cr3+, the caspase-1 p20 subunit was undetectable and IL-1β release decreased down to the level of the negative control, thereby demonstrating that caspase-1 activation and IL-1β release induced by Cr3+ was oxidative stress-dependent. ELISA demonstrated that Cr3+ induced the highest release of IL-1β, while Co2+ had no or limited effects. In the presence of Ni2+, the addition of L-AA (2 mM) also decreased IL-1β release, below the level of the negative control, suggesting that IL-1β release induced by Ni2+ was also oxidative stress-dependent. Finally, when present during both priming with LPS and activation with Cr3+, JSH-23 blocked IL-1β release, demonstrating NF-κB involvement. Overall, this study showed that while both Cr3+ and Ni2+ may be inducing inflammasome activation, Cr3+ is likely a more potent activator, acting through oxidative stress and the NF-κB signaling pathway.
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Affiliation(s)
| | - Isabelle Catelas
- Department of Mechanical Engineering, University of Ottawa, Ottawa, Ontario, Canada
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
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Koller D, Bramhall P, Devoy J, Goenaga-Infante H, Harrington CF, Leese E, Morton J, Nuñez S, Rogers J, Sampson B, Powell JJ. Analysis of soluble or titanium dioxide derived titanium levels in human whole blood: consensus from an inter-laboratory comparison. Analyst 2018; 143:5520-5529. [DOI: 10.1039/c8an00824h] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Exposure to titanium (Ti),viathe ingestion of pigment grade Ti dioxide (TiO2), is commonplace for westernised populations.
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Affiliation(s)
- D. Koller
- Biomineral Research Group
- Department of Veterinary Medicine
- University of Cambridge
- Cambridge
- UK
| | - P. Bramhall
- University Hospital of Wales TRACE ELEMENT LABORATORY
- Department of Medical Biochemistry and Immunology
- Cardiff
- UK
| | - J. Devoy
- INRS
- Unité de Génération d'atmosphères et de Chimie Analytique Toxicologique
- 54519 Vandoeuvre-lès-Nancy
- France
| | | | | | - E. Leese
- Health and Safety Executive
- Biological Monitoring
- Buxton
- UK
| | - J. Morton
- Health and Safety Executive
- Biological Monitoring
- Buxton
- UK
| | - S. Nuñez
- LGC Limited
- Inorganic Analysis
- Teddington
- UK
| | - J. Rogers
- University Hospital of Wales TRACE ELEMENT LABORATORY
- Department of Medical Biochemistry and Immunology
- Cardiff
- UK
| | - B. Sampson
- Charing Cross Hospital
- SAS Trace Element Laboratory
- London
- UK
| | - J. J. Powell
- Biomineral Research Group
- Department of Veterinary Medicine
- University of Cambridge
- Cambridge
- UK
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A Comparison of Blood Metal Ions in Total Hip Arthroplasty Using Metal and Ceramic Heads. J Arthroplasty 2016; 31:2215-20. [PMID: 27108055 DOI: 10.1016/j.arth.2016.03.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 02/29/2016] [Accepted: 03/11/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In recent time, metal ion debris and adverse local tissue reaction have reemerged as an area of clinical concern with the use of large femoral heads after total hip arthroplasty (THA). METHODS Between June 2014 and January 2015, 60 patients with a noncemented THA using a titanium (titanium, molybdenum, zirconium, and iron alloy) femoral stem and a V40 trunnion were identified with a minimum 5-year follow-up. All THAs had a 32- or 36-mm metal (n = 30) or ceramic (n = 30) femoral head coupled with highly cross-linked polyethylene. Cobalt, chromium, and nickel ions were measured. RESULTS Patients with metal heads had detectable cobalt and chromium levels. Cobalt levels were detectable in 17 (56.7%) patients with a mean of 2.0 μg/L (range: <1.0-10.8 μg/L). Chromium levels were detectable in 5 (16.7%) patients with a mean of 0.3 μg/L (range: <1.0-2.2 μg/L). All patients with a ceramic head had nondetectable cobalt and chromium levels. Cobalt and chromium levels were significantly higher with metal heads compared to ceramic heads (P < .01). Cobalt levels were significantly higher with 36-mm metal heads compared with 32-mm heads (P < .01). Seven patients with metal femoral heads had mild hip symptoms, 4 of whom had positive findings of early adverse local tissue reaction on magnetic resonance imaging. All ceramic THA was asymptomatic. CONCLUSION The incidence and magnitude of cobalt and chromium levels is higher in metal heads compared to ceramic heads with this implant system (P < .01). Thirty-six millimeter metal femoral heads result in larger levels of cobalt compared with 32-mm metal heads.
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Osman K, Panagiotidou AP, Khan M, Blunn G, Haddad FS. Corrosion at the head-neck interface of current designs of modular femoral components. Bone Joint J 2016; 98-B:579-84. [DOI: 10.1302/0301-620x.98b5.35592] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 12/10/2015] [Indexed: 11/05/2022]
Abstract
There is increasing global awareness of adverse reactions to metal debris and elevated serum metal ion concentrations following the use of second generation metal-on-metal total hip arthroplasties. The high incidence of these complications can be largely attributed to corrosion at the head-neck interface. Severe corrosion of the taper is identified most commonly in association with larger diameter femoral heads. However, there is emerging evidence of varying levels of corrosion observed in retrieved components with smaller diameter femoral heads. This same mechanism of galvanic and mechanically-assisted crevice corrosion has been observed in metal-on-polyethylene and ceramic components, suggesting an inherent biomechanical problem with current designs of the head-neck interface. We provide a review of the fundamental questions and answers clinicians and researchers must understand regarding corrosion of the taper, and its relevance to current orthopaedic practice. Cite this article: Bone Joint J 2016;98-B:579–84.
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Affiliation(s)
- K. Osman
- Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore HA7 4LP, UK
| | - A. P. Panagiotidou
- Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore HA7 4LP, UK
| | - M. Khan
- University College London, 170 Tottenham
Court Road, London W1T 7HA, UK
| | - G. Blunn
- Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore HA7 4LP, UK
| | - F. S. Haddad
- University College London Hospitals, 235
Euston Road, London, NW1
2BU, UK
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12
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Basic principles and uniform terminology for the head-neck junction in hip replacement. Hip Int 2016; 25:115-9. [PMID: 25362881 DOI: 10.5301/hipint.5000204] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2014] [Indexed: 02/04/2023]
Abstract
Recent problems with large head metal on metal hip replacements have spiked renewed interest in the head-neck junction. A thorough knowledge of the principles of the locking mechanism, the assembly technique and affecting factors on the strength of this junction is needed. Currently a confusing variability in terms is used to describe this junction. This overcomplicates an already complex issue. The purpose of this literature review is to collect and list the different terms used and to propose a uniform terminology. Two authors independently searched the electronic databases of PubMed, CINAHL and MEDLINE with specific key words and combinations according to the PRISMA guidelines. The initial search yielded a total of 518 articles with ultimately 53 articles included in the present analysis. No consensus for a uniform term for the 2 sides of the head-stem junction was found. Since there is already pronounced variability in taper designs between different manufacturers (even so similarly named, e.g. "12/14"), a uniform terminology could be the first step to simplify the situation. "Male" and "female taper" is proposed as the appropriate terminology for the stem and head junction in hip replacement, respectively. The importance of the assembly technique understanding the principles of the locking mechanism is emphasised.
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Golasik M, Herman M, Piekoszewski W. Toxicological aspects of soluble titanium – a review of in vitro and in vivo studies. Metallomics 2016; 8:1227-1242. [DOI: 10.1039/c6mt00110f] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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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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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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Accurate determination of ultra-trace levels of Ti in blood serum using ICP-MS/MS. Anal Chim Acta 2013; 809:1-8. [PMID: 24418127 DOI: 10.1016/j.aca.2013.10.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 09/26/2013] [Accepted: 10/10/2013] [Indexed: 11/22/2022]
Abstract
Ti is frequently used in implants and prostheses and it has been shown before that the presence of these in the human body can lead to elevated Ti concentrations in body fluids such as serum and urine. As identification of the exact mechanisms responsible for this increase in Ti concentrations, and the risks associated with it, are not fully understood, it is important to have sound analytical methods that enable straightforward quantification of Ti levels in body fluids (for both implanted and non-implanted individuals). Until now, only double-focusing sector field ICP-mass spectrometry (SF-ICP-MS) offered limits of detection that are good enough to deal with the very low basal levels of Ti in human serum. This work reports on the development of a novel method for the accurate and precise determination of trace levels of Ti in human serum samples, based on the use of ICP-MS/MS. O2 and NH3/He have been compared as reaction gases. While the use of O2 did not enable to overcome all spectral interferences, it has been shown that conversion of Ti(+) ions into Ti(NH3)6(+) cluster ions by using NH3/He as a reaction gas in an ICP-QQQ-MS system, operated in MS/MS mode, provided interference-free conditions and sufficiently low limits of detection, down to 3 ng L(-1) (instrumental detection limit obtained for the most abundant Ti isotope). The accuracy of the method proposed was evaluated by analysis of a Seronorm Trace Elements Serum L-1 reference material and by comparing the results obtained with those achieved by means of SF-ICP-MS. As a proof-of-concept, the newly developed method was successfully applied to the determination of Ti in serum samples obtained from individuals with and without Ti-based implants. All results were found to be in good agreement with those obtained by means of SF-ICP-MS. The typical basal Ti level in human serum was found to be <1 μg L(-1), while values in the range of 2-6 μg L(-1) were observed for implanted patients.
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Hartmann A, Hannemann F, Lützner J, Seidler A, Drexler H, Günther KP, Schmitt J. Metal ion concentrations in body fluids after implantation of hip replacements with metal-on-metal bearing--systematic review of clinical and epidemiological studies. PLoS One 2013; 8:e70359. [PMID: 23950923 PMCID: PMC3737219 DOI: 10.1371/journal.pone.0070359] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 06/16/2013] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION The use of metal-on-metal (MoM) total hip arthroplasty (THA) increased in the last decades. A release of metal products (i.e. particles, ions, metallo-organic compounds) in these implants may cause local and/or systemic adverse reactions. Metal ion concentrations in body fluids are surrogate measures of metal exposure. OBJECTIVE To systematically summarize and critically appraise published studies concerning metal ion concentrations after MoM THA. METHODS Systematic review of clinical trials (RCTs) and epidemiological studies with assessment of metal ion levels (cobalt, chromium, titanium, nickel, molybdenum) in body fluids after implantation of metalliferous hip replacements. Systematic search in PubMed and Embase in January 2012 supplemented by hand search. Standardized abstraction of pre- and postoperative metal ion concentrations stratified by type of bearing (primary explanatory factor), patient characteristics as well as study quality characteristics (secondary explanatory factors). RESULTS Overall, 104 studies (11 RCTs, 93 epidemiological studies) totaling 9.957 patients with measurement of metal ions in body fluids were identified and analyzed. Consistently, median metal ion concentrations were persistently elevated after implantation of MoM-bearings in all investigated mediums (whole blood, serum, plasma, erythrocytes, urine) irrespective of patient characteristics and study characteristics. In several studies very high serum cobalt concentrations above 50 µg/L were measured (detection limit typically 0.3 µg/L). Highest metal ion concentrations were observed after treatment with stemmed large-head MoM-implants and hip resurfacing arthroplasty. DISCUSSION Due to the risk of local and systemic accumulation of metallic products after treatment with MoM-bearing, risk and benefits should be carefully balanced preoperatively. The authors support a proposed "time out" for stemmed large-head MoM-THA and recommend a restricted indication for hip resurfacing arthroplasty. Patients with implanted MoM-bearing should receive regular and standardized monitoring of metal ion concentrations. Further research is indicated especially with regard to potential systemic reactions due to accumulation of metal products.
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Affiliation(s)
- Albrecht Hartmann
- University Hospital Carl Gustav Carus Dresden, University Centre for Orthopaedics and Trauma Surgery, Dresden, Germany
| | - Franziska Hannemann
- University Hospital Carl Gustav Carus Dresden, University Centre for Orthopaedics and Trauma Surgery, Dresden, Germany
- University Hospital Carl Gustav Carus Dresden, Centre for Evidence-Based Health Care, Dresden, Germany
| | - Jörg Lützner
- University Hospital Carl Gustav Carus Dresden, University Centre for Orthopaedics and Trauma Surgery, Dresden, Germany
| | - Andreas Seidler
- Dresden University of Technology, Occupational and Social Medicine, Dresden, Germany
| | - Hans Drexler
- University Erlangen-Nuremberg, Occupational, Social and Environmental Medicine, Erlangen, Germany
| | - Klaus-Peter Günther
- University Hospital Carl Gustav Carus Dresden, University Centre for Orthopaedics and Trauma Surgery, Dresden, Germany
| | - Jochen Schmitt
- University Hospital Carl Gustav Carus Dresden, Centre for Evidence-Based Health Care, Dresden, Germany
- Dresden University of Technology, Occupational and Social Medicine, Dresden, Germany
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18
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Abstract
Metal-on-metal (MoM) hip arthroplasty was expected to provide benefits over metal-on-polyethylene systems. After widespread placement of MoM implants, outcomes have been disappointing. MoM implants are associated with higher serum levels of metal ions, adverse periarticular soft tissue reactions, and increased long-term failure rates. In light of these findings, it is crucial that patients with MoM implants be closely monitored for adverse effects. MR imaging is ideally suited for assessment of these patients and complements standard clinical evaluation and laboratory testing. This article reviews the background of MoM implants, emerging data on complications, strategies for using MR imaging, and MR imaging findings in patients with reaction to metal.
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Affiliation(s)
- Carson B Campe
- Division of Musculoskeletal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
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19
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Hasegawa M, Yoshida K, Wakabayashi H, Sudo A. Cobalt and chromium ion release after large-diameter metal-on-metal total hip arthroplasty. J Arthroplasty 2012; 27:990-6. [PMID: 22325959 DOI: 10.1016/j.arth.2011.12.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 12/12/2011] [Indexed: 02/01/2023] Open
Abstract
Seventy-five patients underwent unilateral metal-on-metal total hip arthroplasty using a large-diameter head. Serum levels of cobalt and chromium were determined. Significant increases in both cobalt and chromium were observed at 3 months (cobalt, 1.4 μg/L; chromium, 1.4 μg/L) compared with preoperative values (P < .001). At 1 year, the median cobalt and chromium levels were 2.3 and 2.1 μg/L, respectively, and the levels had increased significantly compared with 3 months (P < .001). There were no significant differences between levels of either metal at 1 or 2 years (cobalt, 2.3 μg/L; chromium, 1.6 μg/L). Pseudotumor occurred in 2 hips. Patients with large-diameter metal-on-metal total hip arthroplasty had higher circulating metal ion levels at 3 months and 1 year, with no additional significant increases at 2 years.
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Affiliation(s)
- Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu City, Mie, Japan
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20
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One-year prospective comparative study of three large-diameter metal-on-metal total hip prostheses: serum metal ion levels and clinical outcomes. Orthop Traumatol Surg Res 2012; 98:265-74. [PMID: 22480865 DOI: 10.1016/j.otsr.2011.11.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 10/25/2011] [Accepted: 11/03/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The good clinical outcomes and low wear obtained with 28-mm metal-on-metal implants for total hip replacement prompted the development of large-diameter heads that more closely replicated the normal hip anatomy, with the goal of improving prosthesis stability. However, the blood release of metal ions due to wear at the bearing surfaces and the high rate of groin pain seen with large-diameter implants are causing concern. To determine whether these events are related to the geometry and metal composition of the prosthesis components, we conducted a prospective study of clinical outcomes and serum chromium and cobalt levels 1 year after implantation of three different acetabular cups. HYPOTHESIS Serum levels of metal ions are comparable with different types of large-diameter metal-on-metal total hip prostheses. PATIENTS AND METHODS We compared 24 Durom™ cups (D), 23 M2a Magnum™ cups (M2a), and 20 Conserve Total™ (C) cups regarding serum chromium and cobalt levels, Postel-Merle d'Aubigné (PMA) scores and Oxford Hip Scores (OHS), as well as radiographic cup orientation and position at 1-year follow-up. Mean age was 66 years (45-85 years), mean body mass index was 28 Kg/m(2) (18-45), patients were almost equally divided between males and females, and the reason for hip replacement was primary hip osteoarthritis in 65 patients and avascular necrosis in two. Metal ions were assayed in serum from blood drawn through non-metallic catheters, using mass spectrometry. RESULTS Dislocation occurred in two patients (one D and one M2a) and revision to change the bearing couple was required in two patients in the D group. Serum cobalt levels in the C group were significantly higher (P=0. 0003) than in the two other groups (7.5 μg/L versus 2. 7 μg/L with D and 2. 2 μg/L with M2a). Clinical outcomes were better in the M2a group (PMA, 17.7 [16-18]; and OHS, 15.2 [12-30]; P<0.05). The PMA score and OHS were 17.5 (16-18) and 18.2 (12-42), respectively, with D; and 16.75 (10-18) and 22. 2 (12-42), respectively, with C cups. When all three cup models were pooled, serum ion levels were higher in patients with pain than without pain (chromium, 7.1 μg/L versus 2.1 μg/L [P=0.002], and cobalt, 8 μg/L versus 2.6 μg/L [P=0.0004]). DISCUSSION Serum chrome and cobalt levels increased after metal-on-metal total hip replacement, and the increase was greater with large-diameter implants than previously reported with 28-mm implants. Persistent pain was significantly associated with higher metal ion levels, with a probable cobalt cut-off of about 8 μg/L. Differences in modular head-neck concepts may explain the observed variations.
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21
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Abstract
Cobalt exerts well-known and documented toxic effects on the thyroid, heart and the haematopoietic system, in addition to the occupational lung disease, allergic manifestations and a probably carcinogenic action. Cobalt neurotoxicity is reported in isolated cases, and it has never been systematically treated. Bilateral optic atrophy and retinopathy, bilateral nerve deafness and sensory-motor polyneuropathy have been described long ago as a result of chronic occupational exposure to cobal powder or during long-term treatment of anaemia with cobalt chloride. Recently, some patients with high levels of cobalt released from metal prosthesis have been referred as presenting with tinnitus, deafness, vertigo, visual changes, optic atrophy, tremor and peripheral neuropathy. The aim of this work is to group these cases and to identify a possible mechanism of cobalt neurotoxicity, focusing on hypothetic individual susceptibility such as altered metal-binding proteins, altered transport processes in target cells or polymorphic variation of genetic background.
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Affiliation(s)
- S Catalani
- Department of Experimental and Applied Medicine, Section of Occupational Health and Industrial Hygiene, University of Brescia, Italy
| | - MC Rizzetti
- Department of Medical and Surgical Sciences, Unit of Neurology, University of Brescia, Italy
| | - A Padovani
- Department of Medical and Surgical Sciences, Unit of Neurology, University of Brescia, Italy
| | - P Apostoli
- Department of Experimental and Applied Medicine, Section of Occupational Health and Industrial Hygiene, University of Brescia, Italy
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22
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Abstract
BACKGROUND Metal ions released from arthroplasty devices are largely cleared in urine, leading to high exposure in renal tissues. Validated early markers of renal damage are routinely used to monitor workers in heavy metal industries, and renal risk can be quantified in these industries. It is unclear if the ion levels in patients with metal-on-metal hips are sufficient to cause renal damage. QUESTION Does metal-on-metal (MOM) bearing use over a 10-year period lead to elevation of early renal markers compared with the levels expected in subjects with no metal exposure? METHODS We retrospectively reviewed 31 patients who underwent MOM hip resurfacings 10 years earlier. Whole blood specimens were collected for metal ion analysis, serum for creatinine estimation, and urine for timed metal ion output and renal markers. The renal marker levels of 30 age- and gender-matched subjects with no metal exposure and no known renal problems or diabetes mellitus were used as controls for renal markers. RESULTS Median serum creatinine level in the MOM group was 1.1 mg/dL (interquartile range, 1.0-1.2 mg/dL) and median creatinine clearance was 79.2 mL/min. In this cohort, the number of patients with markers of renal damage above the reference range was comparable to the controls. None of the renal markers were associated with metal levels. CONCLUSION The absence of elevation of renal markers in this cohort 10 years after MOM bearing implantation is reassuring. However, we believe surveillance through further longer-term, large-scale controlled trials are needed to monitor this arthroplasty-induced low-intensity (but long-term) trace element exposure to rule out potential nephrotoxicity.
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23
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Metal Ion release with large-diameter metal-on-metal hip arthroplasty. J Arthroplasty 2011; 26:282-8. [PMID: 20206466 DOI: 10.1016/j.arth.2009.12.013] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Accepted: 12/10/2009] [Indexed: 02/01/2023] Open
Abstract
Preoperative and postoperative ion concentrations were measured in 29 metal-on-metal, large-diameter head total hip arthroplasty (LDH-THA) patients. Mean chromium, cobalt (Co), and titanium levels from LDH-THA were 1.3, 2.2, and 2.7 μg/L at 12 months. The open femoral head design showed significantly higher Co concentrations than the closed design (3.0 vs 1.8 μg/L, P = .037). Compared with previously published ion levels from a hip resurfacing system presenting the same bearing characteristics, Co levels were significantly higher in LDH-THA (2.2 vs 0.7 μg/L, P < .001). This study has demonstrated that the addition of a sleeve with modular junctions and an open femoral head design of LDH-THA causes more Co release than bearing surface wear (157% and 67%, respectively). Even if no pathologic metal ion threshold level has been determined, efforts should be made to minimize its release. We recommend modification or abandonment of the modular junction and femoral head open design for this specific LDH-THA system.
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24
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Devitt BM, Queally JM, Vioreanu M, Butler JS, Murray D, Doran PP, O'Byrne JM. Cobalt ions induce chemokine secretion in a variety of systemic cell lines. Acta Orthop 2010; 81:756-64. [PMID: 21110705 PMCID: PMC3216089 DOI: 10.3109/17453674.2010.537806] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [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 Metal ion toxicity both locally and systemically following MoM hip replacements remains a concern. Cobalt ions have been shown to induce secretion of proinflammatory chemokines locally; however, little is known about their effect systemically. We investigated the in vitro effect of cobalt ions on a variety of cell lines by measuring production of the proinflammatory chemokines IL-8 and MCP-1. METHOD Renal, gastrointestinal, and respiratory epithelium and also neutrophils and monocytes were exposed to cobalt ions at 4, 12, 24, and 48 hours. RESULTS We found that cobalt ions enhanced the secretion of IL-8 and MCP-1 in renal epithelial cells, gastric and colon epithelium, monocytes and neutrophils, and small airway epithelial cells but not in alveolar cells. Secretion of IL-8 and MCP-1 was markedly elevated in renal epithelium, where a 16-fold and 7-fold increase occurred compared to controls. There was a 6-fold and 4-fold increase in IL-8 and MCP-1 secretion in colon epithelium and a 4-fold and 3-fold increase in gastric epithelium. Small airway epithelial cells showed a maximum increase in secretion of 8-fold (IL-8) and of 4-fold (MCP-1). The increase in chemokine secretion observed in alveolar cells was moderate and did not reach statistical significance. Monocytes and neutrophils showed a 2.5-fold and 2-fold increase in IL-8 secretion and a 6-fold and 4-fold increase in MCP-1 secretion at 48 and 24 hours, respectively. INTERPRETATION These data demonstrate the potent bioactivity of cobalt ions in a variety of cell types and the potential to induce a proinflammatory response.
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Affiliation(s)
- Brian M Devitt
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - Joseph M Queally
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - Mihai Vioreanu
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - Joseph S Butler
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - David Murray
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - Peter P Doran
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - John M O'Byrne
- Department of Trauma and Orthopaedic Surgery, Royal College of Surgeons in Ireland, Cappagh National Orthopaedic Hospital, Dublin, Ireland
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Saito S, Ishii T, Mori S, Hosaka K, Ootaki M, Tokuhashi Y. Long-term results of metasul metal-on-metal total hip arthroplasty. Orthopedics 2010; 33. [PMID: 20704108 DOI: 10.3928/01477447-20100625-11] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We assessed 90 total hip arthroplasties (THAs) performed with the Metasul metal-on-metal hip system (Zimmer, Warsaw, Indiana); the patients were monitored for >10 years. The average Harris Hip Score of the patients was 40.5 points preoperatively and 85.8 points at final follow-up. No adverse reactions to the metal debris were observed in patients presenting with symptoms or phenomena such as unexplained pain, joint effusion, bursitis, or pseudotumor. Radiographically, the acetabular component fixation was stable in 86 hips, possibly unstable in 3 hips, and unstable in 1 hip. The unstable hip required revision of the acetabular component. The femoral component was bone-ingrown in 81 hips and stable-fibrous in 9 hips. Distal femoral cortical hypertrophy was seen in 34.4% of hips.Postoperatively, 6 hips dislocated, of which 2 developed recurrent dislocation and required revision of the acetabular component. Dissociation of the polyethylene liner occurred in 2 hips 6 and 12 years postoperatively, respectively, and required revision of the polyethylene liner and the articular head. The survival rate with the endpoint defined as revision surgery and radiologic loosening was 94.4% at mean follow-up (12.3 years). This study found that the Metasul metal-on-metal THA produces excellent long-term results.
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Affiliation(s)
- Shu Saito
- Department of Orthopedic Surgery, Nihon University School of Medicine, Tokyo, Japan.
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26
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Wimmer MA, Fischer A, Büscher R, Pourzal R, Sprecher C, Hauert R, Jacobs JJ. Wear mechanisms in metal-on-metal bearings: the importance of tribochemical reaction layers. J Orthop Res 2010; 28:436-43. [PMID: 19877285 DOI: 10.1002/jor.21020] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Metal-on-metal (MoM) bearings are at the forefront in hip resurfacing arthroplasty. Because of their good wear characteristics and design flexibility, MoM bearings are gaining wider acceptance with market share reaching nearly 10% worldwide. However, concerns remain regarding potential detrimental effects of metal particulates and ion release. Growing evidence is emerging that the local cell response is related to the amount of debris generated by these bearing couples. Thus, an urgent clinical need exists to delineate the mechanisms of debris generation to further reduce wear and its adverse effects. In this study, we investigated the microstructural and chemical composition of the tribochemical reaction layers forming at the contacting surfaces of metallic bearings during sliding motion. Using X-ray photoelectron spectroscopy and transmission electron microscopy with coupled energy dispersive X-ray and electron energy loss spectroscopy, we found that the tribolayers are nanocrystalline in structure, and that they incorporate organic material stemming from the synovial fluid. This process, which has been termed "mechanical mixing," changes the bearing surface of the uppermost 50 to 200 nm from pure metallic to an organic composite material. It hinders direct metal contact (thus preventing adhesion) and limits wear. This novel finding of a mechanically mixed zone of nanocrystalline metal and organic constituents provides the basis for understanding particle release and may help in identifying new strategies to reduce MoM wear.
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Affiliation(s)
- Markus A Wimmer
- Department of Orthopedic Surgery, Rush University Medical Center, 1653 West Congress Parkway, Chicago, Illinois 60612, USA.
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27
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Visuri T, Pulkkinen P, Paavolainen P, Pukkala E. Cancer risk is not increased after conventional hip arthroplasty. Acta Orthop 2010; 81:77-81. [PMID: 20178446 PMCID: PMC2856208 DOI: 10.3109/17453671003667150] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Wear debris from conventional total hip arthroplasty (THA) induces chromosomal aberrations and DNA damage, which may promote cancerogenesis. A long latent period is required for solid tumors. We therefore re-analyzed a large THA cohort for cancer. PATIENTS AND METHODS We updated a cohort of 24,636 patients with primary osteoarthritis and metal-on-polyethylene THA who had been entered in the Finnish Arthroplasty Register between 1980 and 1995, and linked it to the Finnish Cancer Registry for cancer risk assessment up to 2005. The mean follow-up time was 13 years. The numbers of cancer cases observed were compared with expected rates based on incidence in the general population. RESULTS The standardized incidence ratio (SIR) for the whole follow-up period was 0.95 (95% confidence interval (CI): 0.92-0.97). After 10 years of follow-up, the SIR was equal to that in the normal population (SIR = 0.98, 95% CI: 0.94-1.03). Incidence of lung cancer was low throughout the follow-up time and that of prostate cancer was slightly elevated. The incidence rates for all other forms of cancer did not deviate significantly from those in the normal population. INTERPRETATION We found no increased cancer risk in patients with conventional THA after an average of 13 years and up to 25 years of follow-up.
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Affiliation(s)
- Tuomo Visuri
- Research Department, Centre for Military Medicine
| | | | | | - Eero Pukkala
- Finnish Cancer Registry, Helsinki and School of Public Health, University of TampereFinland
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28
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Vendittoli PA, Roy A, Mottard S, Girard J, Lusignan D, Lavigne M. Metal ion release from bearing wear and corrosion with 28 mm and large-diameter metal-on-metal bearing articulations: a follow-up study. ACTA ACUST UNITED AC 2010; 92:12-9. [PMID: 20044673 DOI: 10.1302/0301-620x.92b1.22226] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We have updated our previous randomised controlled trial comparing release of chromium (Cr) and cobalt (Co) ions and included levels of titanium (Ti) ions. We have compared the findings from 28 mm metal-on-metal total hip replacement, performed using titanium CLS/Spotorno femoral components and titanium AlloFit acetabular components with Metasul bearings, with Durom hip resurfacing using a Metasul articulation or bearing and a titanium plasma-sprayed coating for fixation of the acetabular component. Although significantly higher blood ion levels of Cr and Co were observed at three months in the resurfaced group than in total hip replacement, no significant difference was found at two years post-operatively for Cr, 1.58 microg/L and 1.62 microg/L respectively (p = 0.819) and for Co, 0.67 microg/L and 0.94 microg/L respectively (p = 0.207). A steady state was reached at one year in the resurfaced group and after three months in the total hip replacement group. Interestingly, Ti, which is not part of the bearing surfaces with its release resulting from metal corrosion, had significantly elevated ion levels after implantation in both groups. The hip resurfacing group had significantly higher Ti levels than the total hip replacement group for all periods of follow-up. At two years the mean blood levels of Ti ions were 1.87 microg/L in hip resurfacing and and 1.30 microg/L in total hip replacement (p = 0.001). The study confirms even with different bearing diameters and clearances, hip replacement and 28 mm metal-on-metal total hip replacement produced similar Cr and Co metal ion levels in this randomised controlled trial study design, but apart from wear on bearing surfaces, passive corrosion of exposed metallic surfaces is a factor which influences ion concentrations. Ti plasma spray coating the acetabular components for hip resurfacing produces significantly higher release of Ti than Ti grit-blasted surfaces in total hip replacement.
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Affiliation(s)
- P-A Vendittoli
- Maisonneueve-Rosemont Hospital, University of Montreal, Quebec, Canada.
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Afolaranmi GA, Tettey JNA, Murray HM, Meek RMD, Grant MH. The effect of anticoagulants on the distribution of chromium VI in blood fractions. J Arthroplasty 2010; 25:118-20. [PMID: 19056207 DOI: 10.1016/j.arth.2008.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 07/08/2008] [Accepted: 10/20/2008] [Indexed: 02/01/2023] Open
Abstract
Metal-on-metal resurfacing arthroplasty is associated with elevated circulating levels of cobalt and chromium ions. To establish the long-term safety of metal-on-metal resurfacing arthroplasty, it has been recommended that during clinical follow-up of these patients, the levels of these metal ions in blood be monitored. In this article, we provide information on the distribution of chromium VI ions (the predominant form of chromium released by cobalt-chrome alloys in vivo and in vitro) in blood fractions. Chromium VI is predominantly partitioned into red blood cells compared with plasma (analysis of variance, P < .05). The extent of accumulation in red blood cells is influenced by the anticoagulant used to collect the blood, with EDTA giving a lower partitioning into red cells compared with sodium citrate and sodium heparin.
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Affiliation(s)
- Grace A Afolaranmi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
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Penny JÃ, Overgaard S. Serum chromium levels sampled with steel needle versus plastic IV cannula. Does method matter? J Biomed Mater Res B Appl Biomater 2010; 92:1-4. [DOI: 10.1002/jbm.b.31479] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Distal radius fractures and titanium volar plates: should we take the plates out? J Hand Surg Am 2010; 35:141-3. [PMID: 20117317 DOI: 10.1016/j.jhsa.2009.10.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2009] [Accepted: 10/25/2009] [Indexed: 02/02/2023]
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Abstract
BACKGROUND Biologic-reactivity to implant-debris is the primary determinant of long-term clinical performance. The following reviews: 1) the physical aspects of spinal-implant debris and 2) the local and systemic biologic responses to implant debris. METHODS Methods included are: 1) gravimetric wear analysis; 2) SEM and LALLS; 3) metal-ion analysis; 4) ELISA, toxicity testing, patch testing; and 5) metal-lymphocyte transformation testing (metal-LTT). RESULTS Wear and corrosion of spine-implants produce particles and ions. Particles (0.01-1000 μm) are generally submicron ( <1 µm). Wear rates of metal-on-polymer and metal-on-metal disc arthroplasties are approximately 2-20 and 1 mm(3)/yr, respectively. Metal-on-metal total disc replacement components have significant increases in circulating metal (less than 10-fold that of controls at 4 ppb-Co and 3 ppb-Cr or ng/mL). Debris reactivity is local and systemic. Local inflammation is caused primarily by ingestion of debris by local macrophages, which produce pro-inflammatory cytokines TNFα, IL-1β, IL-6, and PGE2. Systemic responses associated with implant-debris have been limited to hypersensitivity reactions. Elevated amounts of in the liver, spleen, etc of patients with failed TJA have not been associated with remote toxicological or carcinogenic pathology to date. Implant debris are differentially bioreactive. Greater numbers are pro-inflammatory; the smaller-sized debris are more bioreactive by virtue of their greater numbers (dose) for a given amount of implant mass loss (one 100-μm-diameter particle is equivalent in mass to 1 million 1-μm-diameter particles). Elongated particles are pro-inflammatory (ie, aspect ratio of greater than 3). Metal particles are more proinflammatory than polymers, ceteris paribus. CONCLUSION Spinal arthroplasty designs have been in use for more than 20 years internationally; therefore, concerns about neuropathology, toxicity, and carcinogenicity are mitigated. Debris-induced inflammation still depends on the individual and the type of debris. The consequence of debris-induced inflammation is continued; vigilance by physicians is recommended monitoring of spinal implants using physical exams and testing of metal content and bioreactivity, as is planning for the likelihood of revision in younger individuals.
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Affiliation(s)
- Nadim James Hallab
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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Brown TD, Lundberg HJ, Pedersen DR, Callaghan JJ. 2009 Nicolas Andry Award: clinical biomechanics of third body acceleration of total hip wear. Clin Orthop Relat Res 2009; 467:1885-97. [PMID: 19399565 PMCID: PMC2690766 DOI: 10.1007/s11999-009-0854-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 04/08/2009] [Indexed: 01/31/2023]
Abstract
Aseptic loosening attributable to wear-related osteolysis historically has been the predominant cause of failure in THA. Advances in low-wear bearing couples show great promise to substantially reduce this long-standing problem. However, there always has been striking variability in wear rate in any given cohort of patients who are similarly implanted, with some individuals typically experiencing near order-of-magnitude elevations above group mean. Third-body wear is likely a major contributor to many of these most osteolysis-prone outliers. For the patients affected, third-body effects may obviate many of the gains otherwise achieved by contemporary bearing surface improvements. Toward heightening visibility in terms of consequences for patients, this review paper summarizes an interrelated series of investigations quantifying construct level manifestations of third-body wear. Long-term followup of a unique group of patients with elevated third-body challenge shows statistically significant and clinically important wear-rate increases. A series of finite element models, validated physically, shows the linkage of location of third-body damage with variability of volumetric wear-rate acceleration and shows the effects of various implant factors, surgeon factors, and patient factors in the presence of third-body challenge. Finally, a mechanism for third-body debris access to wear-critical locations on the bearing surface is identified analytically and corroborated in laboratory experiments and implant retrievals.
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Affiliation(s)
- Thomas D Brown
- Department of Orthopaedics and Rehabilitation, Orthopaedic Biomechanics Laboratory, University of Iowa, 2181 Westlawn Building, Iowa City, IA 52242, USA.
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Queally JM, Devitt BM, Butler JS, Malizia AP, Murray D, Doran PP, O'Byrne JM. Cobalt ions induce chemokine secretion in primary human osteoblasts. J Orthop Res 2009; 27:855-64. [PMID: 19132727 DOI: 10.1002/jor.20837] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Chemokines are major regulators of the inflammatory response and have been shown to play an important role in periprosthetic osteolysis. Titanium particles have previously been shown to induce IL-8 and MCP-1 secretion in osteoblasts. These chemokines result in the chemotaxis and activation of neutrophils and macrophages, respectively. Despite a resurgence in the use of cobalt-chromium-molybdenum alloys in metal-on-metal arthroplasty, cobalt and chromium ion toxicity in the periprosthetic area has been insufficiently studied. In this study we investigate the in vitro effect of cobalt ions on primary human osteoblast activity. We demonstrate that cobalt ions rapidly induce the protein secretion of IL-8 and MCP-1 in primary human osteoblasts. This elevated chemokine secretion is preceded by an increase in the transcription of the corresponding chemokine gene. Using a Transwell migration chemotaxis assay we also demonstrate that the chemokines secreted are capable of inducing neutrophil and macrophage migration. Furthermore, cobalt ions significantly inhibit osteoblast function as demonstrated by reduced alkaline phosphatase activity and calcium deposition. In aggregate these data demonstrate that cobalt ions can activate transcription of the chemokine genes IL-8 and MCP-1 in primary human osteoblasts. Cobalt ions are not benign and may play an important role in the pathogenesis of osteolysis by suppressing osteoblast function and stimulating the production and secretion of chemokines that attract inflammatory and osteoclastic cells to the periprosthetic area.
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Affiliation(s)
- J M Queally
- UCD Clinical Research Centre, UCD School of Medicine & Medical Sciences, Mater University Hospital, Dublin, Ireland.
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Response to chronic exposure to hexavalent chromium in human monocytes. Toxicol In Vitro 2009; 23:647-52. [DOI: 10.1016/j.tiv.2009.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Revised: 03/04/2009] [Accepted: 03/05/2009] [Indexed: 11/19/2022]
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Lazennec JY, Boyer P, Poupon J, Rousseau MA, Roy C, Ravaud P, Catonné Y. Outcome and serum ion determination up to 11 years after implantation of a cemented metal-on-metal hip prosthesis. Acta Orthop 2009; 80:168-73. [PMID: 19404797 PMCID: PMC2823177 DOI: 10.3109/17453670902947408] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [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 Little is known about the long-term outcome of cemented metal-on-metal hip arthroplasties. We evaluated a consecutive series of metal-on-metal polyethylene-backed cemented hip arthroplasties implanted in patients under 60 years of age. METHODS 109 patients (134 joint replacements) were followed prospectively for mean 9 (7-11) years. The evaluation included clinical score, radiographic assessment, and blood sampling for ion level determination. RESULTS At the final review, 12 hips had been revised, mainly because of aseptic loosening of the socket. Using revision for aseptic loosening as the endpoint, the survival rate at 9 years was 91% for the cup and 99% for the stem. In addition, 35 hips showed radiolucent lines at the bone-cement interface of the acetabulum and some were associated with osteolysis. The median serum cobalt and chromium levels were relatively constant over time, and were much higher than the detection level throughout the study period. The cobalt level was 1.5 microg/L 1 year after implantation, and 1.44 microg/L 9 years after implantation. INTERPRETATION Revisions for aseptic loosening and radiographic findings in the sockets led us to halt metal-on-metal-backed polyethylene cemented hip arthroplasty procedures. If the rigidity of the cemented socket is a reason for loosening, excessive release of metal ions and particles may be involved. Further investigations are required to confirm this hypothesis and to determine whether subluxation, microseparation, and hypersensitivity also play a role.
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Affiliation(s)
- Jean-Yves Lazennec
- Department of Orthopaedic Surgery, Pitié-Salpétrière HospitalParisFrance
| | - Patrick Boyer
- Department of Orthopaedic Surgery, Bichat HospitalParisFrance
| | - Joel Poupon
- Laboratory of Toxicology, Lariboisière HospitalParisFrance
| | | | - Carine Roy
- Department of Statistics, Bichat Hospital, Université Paris Diderot, Asistance Publique-Hopitaux de ParisParisFrance
| | - Philippe Ravaud
- Department of Statistics, Bichat Hospital, Université Paris Diderot, Asistance Publique-Hopitaux de ParisParisFrance
| | - Yves Catonné
- Department of Orthopaedic Surgery, Pitié-Salpétrière HospitalParisFrance
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Chandrasekar CR, Grimer RJ, Carter SR, Tillman RM, Abudu A, Jeys LM. Unipolar proximal femoral endoprosthetic replacement for tumour. ACTA ACUST UNITED AC 2009; 91:401-4. [DOI: 10.1302/0301-620x.91b3.21666] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
We undertook a cemental unipolar proximal femoral endoprosthetic replacement in 131 patients with a mean age of 50 years (2 to 84). Primary malignant tumours were present in 54 patients and 67 had metastatic disease. In addition, eight patients had either lymphoma or myeloma and two had non-oncological disorders. The mean follow-up was 27 months (0 to 180). An acetabular revision was required later in 14 patients, 12 of whom had been under the age of 21 years at the time of insertion of their original prosthesis. The risk of acetabular revision in patients over 21 years of age was 8% at five years compared with 36% in those aged under 21 years. All the unipolar hips in this younger age group required revision within 11 years of the initial operation. We conclude that unipolar replacement should not be used in younger patients and should be avoided in patients with a life expectancy of more than five years.
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Affiliation(s)
| | - R. J. Grimer
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK
| | - S. R. Carter
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK
| | - R. M. Tillman
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK
| | - A. Abudu
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK
| | - L. M. Jeys
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK
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Raghunathan VK, Tettey JNA, Ellis EM, Grant MH. Comparative chronicin vitrotoxicity of hexavalent chromium to osteoblasts and monocytes. J Biomed Mater Res A 2009; 88:543-50. [DOI: 10.1002/jbm.a.31893] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Mabilleau G, Kwon YM, Pandit H, Murray DW, Sabokbar A. Metal-on-metal hip resurfacing arthroplasty: a review of periprosthetic biological reactions. Acta Orthop 2008; 79:734-47. [PMID: 19085489 DOI: 10.1080/17453670810016795] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Metal-on-metal hip resurfacing arthroplasty has undergone a recent resurgence as an alternative treatment option for young and active patients with significant osteoarthritis. The claimed advantages of metal-on-metal hip resurfacing arthroplasty include lower wear rate, preservation of bone stock for subsequent revision procedures, restoration of anatomic hip mechanics, and enhanced stability due to the larger diameter of articulation. A disadvantage, however, is that the metal-on-metal resurfacing releases large amounts of very small wear particles and metal ions. The long-term biological consequences of the exposure to these Co-Cr particles and ions remain largely unknown. The purpose of this review is to provide an overview of the current literature on the adverse periprosthetic biological reactions associated with metal-on-metal hip resurfacing arthroplasty.
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Affiliation(s)
- Guillaume Mabilleau
- Nuffield Department of Orthopaedic Surgery, Institute of Musculoskeletal Science, Botnar Research Centre, University of Oxford, Oxford, UK.
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De Haan R, Pattyn C, Gill HS, Murray DW, Campbell PA, De Smet K. Correlation between inclination of the acetabular component and metal ion levels in metal-on-metal hip resurfacing replacement. ACTA ACUST UNITED AC 2008; 90:1291-7. [PMID: 18827237 DOI: 10.1302/0301-620x.90b10.20533] [Citation(s) in RCA: 360] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We examined the relationships between the serum levels of chromium and cobalt ions and the inclination angle of the acetabular component and the level of activity in 214 patients implanted with a metal-on-metal resurfacing hip replacement. Each patient had a single resurfacing and no other metal in their body. All serum measurements were performed at a minimum of one year after operation. The inclination of the acetabular component was considered to be steep if the abduction angle was greater than 55 degrees. There were significantly higher levels of metal ions in patients with steeply-inclined components (p = 0.002 for chromium, p = 0.003 for cobalt), but no correlation was found between the level of activity and the concentration of metal ions. A highly significant (p < 0.001) correlation with the arc of cover was found. Arcs of cover of less than 10 mm were correlated with a greater risk of high concentrations of serum metal ions. The arc of coverage was also related to the design of the component and to size as well as to the abduction angle of the acetabular component. Steeply-inclined acetabular components, with abduction angles greater than 55 degrees, combined with a small size of component are likely to give rise to higher serum levels of cobalt and chromium ions. This is probably due to a greater risk of edge-loading.
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Affiliation(s)
- R De Haan
- University Hospital Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium.
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41
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Large head metal-on-metal cementless total hip arthroplasty versus 28 mm metal-on-polyethylene cementless total hip arthroplasty: design of a randomized controlled trial. BMC Musculoskelet Disord 2008; 9:136. [PMID: 18842151 PMCID: PMC2576464 DOI: 10.1186/1471-2474-9-136] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 10/08/2008] [Indexed: 11/27/2022] Open
Abstract
Background Osteoarthritis of the hip is successfully treated by total hip arthroplasty with metal-on-polyethylene articulation. Polyethylene wear debris can however lead to osteolysis, aseptic loosening and failure of the implant. Large head metal-on-metal total hip arthroplasty may overcome polyethylene wear induced prosthetic failure, but can increase systemic cobalt and chromium ion concentrations. The objective of this study is to compare two cementless total hip arthroplasties: a conventional 28 mm metal-on-polyethylene articulation and a large head metal-on-metal articulation. We hypothesize that the latter arthroplasties show less bone density loss and higher serum metal ion concentrations. We expect equal functional scores, greater range of motion, fewer dislocations, fewer periprosthetic radiolucencies and increased prosthetic survival with the metal-on-metal articulation. Methods A randomized controlled trial will be conducted. Patients to be included suffer from non-inflammatory degenerative joint disease of the hip, are aged between 18 and 80 and are admitted for primary cementless unilateral total hip arthroplasty. Patients in the metal-on-metal group will receive a cementless titanium alloy acetabular component with a cobalt-chromium liner and a cobalt-chromium femoral head varying from 38 to 60 mm. Patients in the metal-on-polyethylene group will receive a cementless titanium alloy acetabular component with a polyethylene liner and a 28 mm cobalt-chromium femoral head. We will assess acetabular bone mineral density by dual energy x-ray absorptiometry (DEXA), serum ion concentrations of cobalt, chromium and titanium, self reported functional status (Oxford hip score), physician reported functional status and range of motion (Harris hip score), number of dislocations and prosthetic survival. Measurements will take place preoperatively, perioperatively, and postoperatively (6 weeks, 1 year, 5 years and 10 years). Discussion Superior results of large head metal-on-metal total hip arthroplasty over conventional hip arthroplasty have been put forward by experts, case series and the industry, but to our knowledge there is no randomized controlled evidence. Conclusion This randomized controlled study has been designed to test whether large head metal-on-metal cementless total hip arthroplasty leads to less periprosthetic bone density loss and higher serum metal ion concentrations compared to 28 mm metal-on-polyethylene cementless total hip arthroplasty. Trial registration Netherlands Trial Registry NTR1399
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Olmedo DG, Tasat DR, Guglielmotti MB, Cabrini RL. Biodistribution of titanium dioxide from biologic compartments. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2008; 19:3049-3056. [PMID: 18389343 DOI: 10.1007/s10856-008-3438-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Accepted: 03/14/2008] [Indexed: 05/26/2023]
Abstract
The layer of titanium dioxide (TiO(2)) of the implant is chronically exposed to the internal electrolyte milieu in the peri-implant biological compartment. Corrosion results from electrochemical attack and ensuing gradual degradation of the metallic materials and is thus of biological interest when these biomaterials are employed in clinical implantology. Herein we evaluated and compared the chronic effect and the biodistribution of TiO(2) administered subcutaneously or intraperitoneally. We propose that the compartmentalization of titanium in the area of subcutaneous injection would reproduce the biological compartment of the implant and its microenvironment from which metal ions could be released and migrate systemically. Potential TiO(2) deposits were identified and characterized in skin, liver and lung by histological and EDX analyses. After both treatments, the skin, liver, and lungs exhibited histological evidence of TiO(2) deposits. In order to characterize in situ macrophage-like cells, tissue sections were immunohistochemically stained for CD68. Tissue specimens from all organs assayed showed positive staining for anti-macrophage monoclonal antibody CD68 (PGM1). Despite the compartmentalization of titanium within nodular areas in rats treated subcutaneously, systemic migration occurred. We concluded that systemic migration of TiO(2) occurred regardless of the administration route.
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Affiliation(s)
- Daniel G Olmedo
- Department of Oral Pathology, School of Dentistry, University of Buenos Aires, Buenos Aires, Argentina.
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Hosman AH, van der Mei HC, Bulstra SK, Busscher HJ, Neut D. Metal‐on‐metal bearings in total hip arthroplasties: Influence of cobalt and chromium ions on bacterial growth and biofilm formation. J Biomed Mater Res A 2008; 88:711-6. [DOI: 10.1002/jbm.a.31922] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anton H. Hosman
- Department of Biomedical Engineering, University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
- Department of Orthopaedic Surgery, University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Henny C. van der Mei
- Department of Biomedical Engineering, University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Sjoerd K. Bulstra
- Department of Orthopaedic Surgery, University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Henk J. Busscher
- Department of Biomedical Engineering, University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Daniëlle Neut
- Department of Biomedical Engineering, University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
- Department of Orthopaedic Surgery, University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
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Afolaranmi G, Tettey J, Meek R, Grant M. Release of chromium from orthopaedic arthroplasties. Open Orthop J 2008; 2:10-8. [PMID: 19461924 PMCID: PMC2685051 DOI: 10.2174/1874325000802010010] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 12/10/2007] [Accepted: 01/04/2008] [Indexed: 12/12/2022] Open
Abstract
Many orthopaedic implants are composed of alloys containing chromium. Of particular relevance is the increasing number of Cobalt Chromium bearing arthroplasies being inserted into young patients with osteoarthritis. Such implants will release chromium ions. These patients will be exposed to the released chromium for over 50 years in some cases. The subsequent chromium ion metabolism and redistribution in fluid and tissue compartments is complex. In addition, the potential biological effects of chromium are also controversial, including DNA and chromosomal damage, reduction in CD8 lymphocyte levels and possible hypersensitivity reactions (ALVAL). The establishment of these issues and the measurement of chromium in biological fluids is the subject of this review.
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Affiliation(s)
| | - J Tettey
- Strathclyde Institute of Pharmacy and Biomedical Sciences
| | - R.M.D Meek
- Department of Orthopaedic Surgery, Southern General Hospital, Glasgow, UK
| | - M.H Grant
- Bioengineering Unit, University of Strathclyde, UK
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45
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Bilgili MG. Re: Serum metal levels and bearing surfaces in total hip arthroplasty. J Arthroplasty 2008; 23:156; author reply 156-7. [PMID: 18165048 DOI: 10.1016/j.arth.2007.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Accepted: 09/06/2007] [Indexed: 02/01/2023] Open
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