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Semi-Automated Determination of Heavy Metals in Autopsy Tissue Using Robot-Assisted Sample Preparation and ICP-MS. Molecules 2021; 26:molecules26133820. [PMID: 34201553 PMCID: PMC8270248 DOI: 10.3390/molecules26133820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 11/17/2022] Open
Abstract
The endoprosthetic care of hip and knee joints introduces multiple materials into the human body. Metal containing implant surfaces release degradation products such as particulate wear and corrosion debris, metal-protein complexes, free metallic ions, inorganic metal salts or oxides. Depending on the material composition of the prostheses, a systemic exposure occurs and may result in increasing metal concentrations in body fluids and tissues especially in the case of malfunctions of the arthroplasty components. High concentrations of Cr, Co, Ni, Ti and Al affect multiple organs such as thyroid, heart, lung and cranial nerves and may lead to metallosis, intoxications, poly-neuropathy, retinopathy, cardiomyopathy and the formation of localized pseudo tumors. The determination of the concentration of metals in body fluids and tissues can be used for predicting failure of hip or knee replacements to prevent subsequent severe intoxications. A semi-automated robot-assisted measurement system is presented for the determination of heavy metals in human tissue samples using inductively coupled plasma mass spectrometry (ICP-MS). The manual and automated measurement processes were similarly validated using certified reference material and the results are compared and discussed. The automation system was successfully applied in the determination of heavy metals in human tissue; the first results are presented.
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Kasai K, Segawa R, Onodera R, Asakawa S, Hiratsuka M, Hirasawa N. Lactate released from human fibroblasts enhances Ni elution from Ni plate. Toxicology 2021; 453:152723. [PMID: 33596451 DOI: 10.1016/j.tox.2021.152723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 11/19/2022]
Abstract
Elution of Ni ions from medical devices induces inflammation and toxicity. We previously reported that elution of Ni ions from Ni wires induced COX-2 expression and increased lactate production, but whether lactate is involved in the further elution of Ni ions remains unclear. In this study, using KMST-6, a human fibroblast cell line, we examined the molecular mechanisms by which Ni ions increase lactate release and the role of lactate in enhancing the elution of Ni ions. When KMST-6 cells were incubated on a Ni plate or stimulated with NiCl2 (1 mM), the expression of glucose transporter 1 (GLUT1), hexokinase 2 (HK2), and lactate dehydrogenase A (LDHA), and the release of lactate were enhanced. The NiCl2 (1 mM)-induced expression of these genes was inhibited by a hypoxia-inducible factor-1α (HIF-1α) inhibitor, PX-478 (10-25 μM). Stimulation of cells with a prolyl hydroxylase domain (PHD) inhibitor, roxadustat, increased the expression of these genes, lactate release, and elution of Ni ions at 10 μM. A monocarboxylate transporter-4 (MCT4) inhibitor, syrosingopine, inhibited lactate release from roxadustat-treated cells and reduced the elution of Ni ions by the cells at 10 μM. Finally, syrosingopine (10 μM) reduced the elution of Ni ions by the cells from the Ni plate. These results suggest that elution of Ni ions from metals promotes the production of lactate via HIF-1α-mediated gene expression and causes further Ni elution. Thus, Ni ions show a positive feedback mechanism of Ni elution, and this step may be potentially targeted to protect against metal elution from metal devices.
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Affiliation(s)
- Koji Kasai
- Laboratory of Pharmacotherapy of Life-Style Related Diseases, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Miyagi, Japan
| | - Ryosuke Segawa
- Laboratory of Pharmacotherapy of Life-Style Related Diseases, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Miyagi, Japan
| | - Ryo Onodera
- Laboratory of Pharmacotherapy of Life-Style Related Diseases, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Miyagi, Japan
| | - Sanki Asakawa
- Laboratory of Pharmacotherapy of Life-Style Related Diseases, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Miyagi, Japan
| | - Masahiro Hiratsuka
- Laboratory of Pharmacotherapy of Life-Style Related Diseases, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Miyagi, Japan
| | - Noriyasu Hirasawa
- Laboratory of Pharmacotherapy of Life-Style Related Diseases, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Miyagi, Japan.
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Pozzuoli A, Berizzi A, Crimì A, Belluzzi E, Frigo AC, Conti GD, Nicolli A, Trevisan A, Biz C, Ruggieri P. Metal Ion Release, Clinical and Radiological Outcomes in Large Diameter Metal-on-Metal Total Hip Arthroplasty at Long-Term Follow-Up. Diagnostics (Basel) 2020; 10:diagnostics10110941. [PMID: 33198180 PMCID: PMC7698262 DOI: 10.3390/diagnostics10110941] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 02/08/2023] Open
Abstract
Total hip arthroplasty (THA) with metal-on-metal (MoM) bearings have shown problems of biocompatibility linked to metal ion release at the local level causing an adverse reaction to metal debris (ARMD) and at a systemic level. The aim of this study was to evaluate clinical and radiological outcomes, and metal ion concentrations in the blood and urine of patients who underwent THA with the LIMA Met-Met hip system. Patients with ceramic-on-ceramic (CoC) bearings were included as a control group. In this study, 68 patients were enrolled: 34 with MoM THAs and 34 with CoC THAs. Patients were evaluated clinically (Harris Hip Score, SF-36) and radiologically at a median of 7.4 years after surgery. Whole blood and urinary cobalt and chromium levels were also assessed. Both types of implants were comparable in terms of clinical and functional results. Ion levels were significantly higher in the MoM group compared with CoC group 7 years after surgery. No correlations were found between metal ion levels and patient demographics, functional and radiological outcomes, and prosthesis features. Patient monitoring is thus advised to establish if prosthesis revision is necessary, especially in the case of MoM THA.
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Affiliation(s)
- Assunta Pozzuoli
- Laboratory of Musculoskeletal Pathology and Oncology, Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
- Correspondence: (A.P.); (E.B.); Tel.: +39-0498213348 (A.P. & E.B.)
| | - Antonio Berizzi
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
| | - Alberto Crimì
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
| | - Elisa Belluzzi
- Laboratory of Musculoskeletal Pathology and Oncology, Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
- Correspondence: (A.P.); (E.B.); Tel.: +39-0498213348 (A.P. & E.B.)
| | - Anna Chiara Frigo
- Epidemiology and Public Health Unit, Department of Cardiac Thoracic Vascular Sciences and Public Health, Biostatistics, University of Padova, Via Loredan 18, 35131 Padova, Italy;
| | - Giorgio De Conti
- Department of Radiology, University Hospital of Padova, Via Giustiniani 2, 35128 Padova, Italy;
| | - Annamaria Nicolli
- Laboratory of Industrial Toxicology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (A.N.); (A.T.)
| | - Andrea Trevisan
- Laboratory of Industrial Toxicology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (A.N.); (A.T.)
| | - Carlo Biz
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
| | - Pietro Ruggieri
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
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Marie-Hardy L, O'Laughlin P, Bonnin M, Ait Si Selmi T. Are dual mobility cups associated with increased metal ions in the blood? Clinical study of nickel and chromium levels with 29 months' follow-up. Orthop Traumatol Surg Res 2018; 104:1179-1182. [PMID: 30297115 DOI: 10.1016/j.otsr.2018.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 07/28/2018] [Accepted: 08/25/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Dual mobility cups have become the implant of choice for older patients with a high risk of dislocation. However, to our knowledge, no study has explored the possibility of metal ion production with these implants that incorporate a polyethylene-on-metal bearing. This led us to conduct a prospective study to determine whether use of a dual mobility cup is accompanied by increased levels of nickel and chromium in the blood. HYPOTHESIS Use of a dual mobility cup is accompanied by an increase of nickel and chromium levels in the blood. METHODS Between 2012 and 2015, 16 consecutive patients were enrolled in the study. They underwent primary hip arthroplasty with a ceramic Biolox™ head (CeramTec, Plochingen, Germany), Corail™ titanium alloy stem (DePuy Synthes, Saint Priest, France) and a Novae™ dual mobility cup (SERF, Décines-Charpieu, France) consisting of 19% chromium (Cr) and 13-15% nickel (Ni). Patients who had other potential sources of nickel or chromium in their body (joint implants, dental implants, etc.) were excluded. The blood levels (μg/L) of nickel and chromium were measured preoperatively and at 2 years' follow-up by an independent laboratory (Biomnis) using inductively coupled plasma mass spectrometry. The upper limits set by the laboratory were<0.87μg/L for chromium and<1.0μg/L for nickel. AP and lateral X-rays of the pelvis were taken preoperatively and at each postoperative follow-up visit to look for signs of loosening. The Postel-Merle-d'Aubigné (PMA) score was determined preoperatively and at each postoperative follow-up visit. Surgical revision procedures for any cause were also documented. RESULTS The mean follow-up was 29 months [13-39]. Preoperatively, blood nickel ion levels were measured in 7 patients; they were below 1μg/L in 6 patients (86%) and at 1.5μg/L in 1 patient (14%). The mean preoperative chromium ion levels (n=7) was 0.2μg/L [0-0.8μg/L]. Postoperatively, all 16 enrolled patients had their blood ion levels checked at a mean follow-up of 29 months. The nickel ion levels averaged 1.69±1.49 [0.2-5.6] (with 4/16 having>2μg/L and 12/16>1μg/L) and the chromium ion levels averaged 0.5±0.11 [0.4-0.7] (with no patients>0.7μg/L). There were no signs of loosening or osteolysis on the follow-up radiographs. The mean PMA score at 2 years was 17.8 [17,18]. CONCLUSION We found that dual mobility cups generate increased nickel but not chromium ions in the blood. The levels measured are comparable to those for other orthopedic implants such as spine implants. The clinical consequences of these increased levels are not known. Nevertheless, there were no clinical or radiological signs of loosening, although the follow-up was only 2 years. LEVEL OF EVIDENCE IV, Cohort study.
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Affiliation(s)
- Laura Marie-Hardy
- Centre orthopédique Paul-Santy-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France.
| | - Padhraig O'Laughlin
- Centre orthopédique Paul-Santy-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France
| | - Michel Bonnin
- Centre orthopédique Paul-Santy-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France
| | - Tarik Ait Si Selmi
- Centre orthopédique Paul-Santy-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France
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Maezawa K, Nozawa M, Yuasa T, Sugimoto M, Kaneko K. Changes in serum chromium levels over 12 years after Metasul metal-on-metal total hip arthroplasty. J Orthop 2018; 15:201-204. [PMID: 29657468 DOI: 10.1016/j.jor.2018.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 01/13/2018] [Indexed: 10/17/2022] Open
Abstract
We reported the longitudinal changes in serum chromium levels over a minimum of 7 years postoperatively in five men and 25 women with a mean age of 60.3 years after primary unilateral total hip arthroplasty with a Metasul metal-on-metal articulation. The serum chromium ion level showed little variation (0.6-1.2 μg/L) from 2 to 12 years postoperatively in 16/30 patients after unilateral primary Metasul metal-on-metal total hip arthroplasty. On the other hand, the serum chromium level stayed high or showed gradual elevation in 8/30 patients, even though they had well-fixed and well-functioning prostheses.
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Affiliation(s)
- Katsuhiko Maezawa
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu City, Chiba, 279-0021, Japan
| | - Masahiko Nozawa
- Department of Orthopaedic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Takahito Yuasa
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu City, Chiba, 279-0021, Japan
| | - Munehiko Sugimoto
- Department of Orthopaedic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Kazuo Kaneko
- Department of Orthopaedic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
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Shawaf T, Almathen F, Meligy A, El-Deeb W, Al-Bulushi S. Biochemical analysis of some serum trace elements in donkeys and horses in Eastern region of Kingdom of Saudi Arabia. Vet World 2017; 10:1269-1274. [PMID: 29184375 PMCID: PMC5682274 DOI: 10.14202/vetworld.2017.1269-1274] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 09/29/2017] [Indexed: 11/25/2022] Open
Abstract
Aim: Little is known about the serum levels of trace elements in donkeys and horses in Saudi Arabia. This study aimed to investigate the levels of some trace elements in these two species in the eastern region of Saudi Arabia and to compare the obtained results with the reference values. Materials and Methods: Seventeen Arabian horses and twenty eight Hassawi donkeys were randomly selected for this study. All of the studied healthy animals were kept under a uniform feeding protocol without any minerals supplementations. Atomic absorption spectrometer is used to estimate the serum concentrations of selenium (Se), manganese (Mn), chromium (Cr), copper (Cu), iron (Fe), and zinc (Zn) in the analyzed samples. Results: Significant differences between horses and donkeys were observed in three of the studied elements (Se, Mn, and Cr). Statistically significant differences were found in serum Se and Cr between male and female horses. The male donkey showed higher Mn, Cu, and Zn levels than female animals. Conclusion: The obtained results of trace element levels in serum of Hassawi donkeys and Arabian horses in Saudi Arabia are considered as the first values to be published for these breeds. When compared to other animals, the measured amounts of Se, Mn, Cr, Cu, Fe, and Zn in the serum of horses and donkey are often differed, possibly because of the varying living or feeding conditions. Moreover, there were some differences in some of the trace elements concentrations related to animal’s gender and species (horses and donkeys), which will be considered in the interpretation of the laboratory data.
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Affiliation(s)
- Turke Shawaf
- Department of Clinical Studies, College of Veterinary Medicine, King Faisal University, 400 Al-Hasa, 31982, Saudi Arabia
| | - Faisal Almathen
- Department of Veterinary Public Health and Animal Husbandry, College of Veterinary Medicine, King Faisal University, 400 Al-Hasa, 31982, Saudi Arabia
| | - Ahmad Meligy
- Department of Clinical Studies, College of Veterinary Medicine, King Faisal University, 400 Al-Hasa, 31982, Saudi Arabia.,Department of Physiology, Agricultural Research Center, Egypt
| | - Wael El-Deeb
- Department of Clinical Studies, College of Veterinary Medicine, King Faisal University, 400 Al-Hasa, 31982, Saudi Arabia.,Department of Veterinary Medicine, Infectious Diseases and Fish Diseases, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt
| | - Shahab Al-Bulushi
- Department of Clinical Studies, College of Veterinary Medicine, King Faisal University, 400 Al-Hasa, 31982, Saudi Arabia
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Christensen TJ, Samant SA, Shin AY. Making Sense of Metal Allergy and Hypersensitivity to Metallic Implants in Relation to Hand Surgery. J Hand Surg Am 2017; 42:737-746. [PMID: 28709788 DOI: 10.1016/j.jhsa.2017.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 06/12/2017] [Indexed: 02/02/2023]
Abstract
All metals implanted into a biological system undergo some degree of corrosion depending upon its composition. The electrochemical process of corrosion produces free metal ions, which may activate the host's immune system through a variety of mechanisms. Whereas dermal metal hypersensitivity is common, affecting 10% to 15% of the population, the immune reaction from implanted metals is much less common (< 0.1%), but has been associated with metal allergy and hypersensitivity producing a multitude of patient symptoms. Superficial symptoms may be mild to severe forms of dermatitis, urticaria, pruritus, and vasculitis, whereas deep sequelae include metallosis-related pseudotumor, implant loosening, and joint stiffness. Currently, there are clinical tests to evaluate patients for metal hypersensitivity, but there is little agreement regarding the ideal timing and clinical situation prompting the work-up of a patient for a metal allergy or hypersensitivity. An understanding of the epidemiology, etiology, basic science, diagnostic testing, and treatment of patients with suspected metal allergy, as it pertains to the current literature, will aid orthopedic and plastic surgeons of all subspecialties in the management of patients requiring metallic implants.
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Affiliation(s)
| | | | - Alexander Y Shin
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN.
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Liu Y, Yang X, Wang W, Wu X, Zhu H, Liu F. Melatonin counteracts cobalt nanoparticle‑induced cytotoxicity and genotoxicity by deactivating reactive oxygen species‑dependent mechanisms in the NRK cell line. Mol Med Rep 2017; 16:4413-4420. [PMID: 28849220 PMCID: PMC5647000 DOI: 10.3892/mmr.2017.7309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 06/09/2017] [Indexed: 11/05/2022] Open
Abstract
Cobalt nanoparticles (CoNPs) released from metal-on-metal implants have caused considerable concern. Oxidative stress is associated with the mechanism underlying cobalt-induced cytotoxicity and genotoxicity. The indolamine melatonin exhibits protective effects against damage induced by metals. The present study investigated the in vitro effects of melatonin on the cytotoxicity and genotoxicity induced by CoNPs. CoNPs (20–50 nm in diameter) were employed in the present study. NRK rat kidney cells were exposed to various concentrations of CoNPs for different durations. The results of the current study demonstrated that CoNPs significantly increased reactive oxygen species (ROS) production and reduced cell viability, as determined by dichlorofluorescein diacetate, and Cell Counting Kit-8 and lactate dehydrogenase leakage assays, respectively. Furthermore, western blot analysis demonstrated that CoNPs led to an increase in the ratio of Bcl-2-associated X/Bcl-2, and the expression of cleaved caspase-3 was upregulated, which indicated increased apoptosis levels. Genotoxicity was detected by a comet assay, which revealed a significant induction in DNA damage, as determined by increases in the tail DNA % and olive tail moment. Phosphorylated-histone H2AX foci analyses by immunofluorescence also demonstrated that CoNPs induced DNA-double strand breaks. However, cellular treatment with melatonin reduced the effects of CoNPs on NRK cells by reducing the production of ROS. The results of the present study demonstrated that CoNPs induced cytotoxicity and genotoxicity by increasing oxidative stress, and melatonin may have pharmacological potential in protecting against the damaging effects of CoNPs following total hip arthroplasty.
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Affiliation(s)
- Yake Liu
- Department of Orthopedics, The Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Xiaoyou Yang
- Department of Orthopedics, The Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Wei Wang
- Department of Orthopedics, The Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Xuefei Wu
- Department of Orthopedics, The Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Hai Zhu
- Department of Orthopedics, The Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Fan Liu
- Department of Orthopedics, The Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
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Awoyemi OV, Okotie UJ, Oyagbemi AA, Omobowale TO, Asenuga ER, Ola-Davies OE, Ogunpolu BS. Cobalt chloride exposure dose-dependently induced hepatotoxicity through enhancement of cyclooxygenase-2 (COX-2)/B-cell associated protein X (BAX) signaling and genotoxicity in Wistar rats. ENVIRONMENTAL TOXICOLOGY 2017; 32:1899-1907. [PMID: 28303633 DOI: 10.1002/tox.22412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/17/2017] [Accepted: 02/21/2017] [Indexed: 06/06/2023]
Abstract
Cobalt chloride (CoCl2 ) is one of the many environmental contaminants, used in numerous industrial sectors. It is a pollutant with deadly toxicological consequences both in developing and developed countries. We investigated toxicological impact of CoCl2 on hepatic antioxidant status, apoptosis, and genotoxicity. Forty Wistar rats were divided into four groups, 10 rats per group: Group 1 served as control and received clean tap water orally; Group 2 received CoCl2 solution (150 mg/L); Group 3 received CoCl2 solution (300 mg/L); and Group 4 received CoCl2 (600 mg/L) in drinking water for 7 days, respectively. Exposure of rats to CoCl2 led to a significant decline in hepatic antioxidant enzymes together with significant increase in markers of oxidative stress. Immunohistochemistry revealed dose-dependent increase in cyclooxygenase-2 and BAX expressions together with increased frequency of Micronucleated Polychromatic Erythrocytes. Combining all, CoCl2 administration led to hepatic damage through induction of oxidative stress, inflammation, and apoptosis.
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Affiliation(s)
| | - Ufuoma Jowafe Okotie
- Federal College of Animal Health and Production Technology, Moor Plantation, Ibadan, Nigeria
| | - Ademola Adetokunbo Oyagbemi
- Department of Veterinary Physiology, Biochemistry and Pharmacology, Faculty of Veterinary Medicine, University of Ibadan, Ibadan, Nigeria
| | - Temidayo Olutayo Omobowale
- Department of Veterinary Medicine, Faculty of Veterinary Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ebunoluwa Racheal Asenuga
- Department of Veterinary Biochemistry, Faculty of Veterinary Medicine, University of Benin, Benin, Nigeria
| | - Olufunke Eunice Ola-Davies
- Department of Veterinary Physiology, Biochemistry and Pharmacology, Faculty of Veterinary Medicine, University of Ibadan, Ibadan, Nigeria
| | - Blessing Seun Ogunpolu
- Department of Veterinary Medicine, Faculty of Veterinary Medicine, University of Ibadan, Ibadan, Nigeria
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A 5-year survival analysis of 160 Biomet Magnum M2 metal-on-metal total hip prostheses. Hip Int 2017; 26:50-6. [PMID: 26541184 DOI: 10.5301/hipint.5000293] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Large-head metal-on-metal (MoM) total hip arthroplasties (THA) are associated with high failure rates and possible pseudotumour formation. This study reports the first results of 160 Biomet Magnum M2 large-head MoM total hip articulations. PATIENTS AND METHODS From 2006 to 2010 the Reinier de Graaf Hospital implanted 160 large-head Magnum M2 MoM THAs (Biomet Inc. Warsaw, Indiana, USA) in 150 patients. These patients were recalled after a warning from the Dutch Orthopaedic Association. Patients were offered a clinical and radiographic assessment of the hip prosthesis, serum control on cobalt and chromium ions, and an ultrasound of the hip. If indicated, additional MARS-MRI or CT scan was performed. Descriptive statistical analysis, correlations, t-tests, non-parametric tests and implant survival were calculated. RESULTS The mean follow-up was 6.1 years (4.8-8.4). A cumulative survival rate of 93.1% (95% CI: 88.3-98%) was found after 5 years. Reasons for revision were loosening, pain, infection and pseudotumour formation. The prevalence of pseudotumour formation around the prostheses was 8.75%. CONCLUSIONS This study reports the first results of 160 MoM THAs implanted in our clinic from 2006-2010. In total, 13 (8.1%) of the THAs were eligible for revision after the recall. In most patients the reason for revision was pseudotumour formation. A total of 14 (8.75%) pseudotumours were diagnosed at the first recall. These results show that a comprehensive follow-up strategy is essential for MoM THAs to promptly identify and manage early complications.
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Akinrinde AS, Omobowale O, Oyagbemi A, Asenuga E, Ajibade T. Protective effects of kolaviron and gallic acid against cobalt-chloride-induced cardiorenal dysfunction via suppression of oxidative stress and activation of the ERK signaling pathway. Can J Physiol Pharmacol 2016; 94:1276-1284. [DOI: 10.1139/cjpp-2016-0197] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cobalt (Co) toxicity is a potential public health problem due to recent renewed use of Co in orthopedic implants, dietary supplements, and blood doping in athletes and horses. We investigated the protective roles of kolaviron (KV), a bi-flavonoid of Garcinia kola, and gallic acid (GA) on cobalt chloride (CoCl2)-induced cardiorenal damage in rats. CoCl2 caused significant increases (p < 0.05) in serum creatine kinase–myocardial band (CK-MB), lactate dehydrogenase (LDH), aspartate transaminase (AST), xanthine oxidase (XO), urea, creatinine, malondialdehyde, H2O2, nitric oxide, as well as C-reactive protein expression, along with significant (p < 0.05) reduction in cardiac and renal expression of extracellular signal regulated kinase (ERK) and the activities of superoxide dismutase, catalase, and glutathione S-transferase. KV and GA prevented the toxic effects of CoCl2 by stimulating ERK expression and reversing Co-induced biochemical changes. Administration of CoCl2 alone did not significantly alter ECG patterns in the rats, although co-treatment with KV (200 mg/kg) produced QT-segment prolongation and also appeared to potentiate Co hypotension. Histopathology of the heart and kidneys of rats treated with KV and GA confirmed the biochemical data. KV and GA thus protected against cardiac and renal damage in Co intoxication via antioxidant and (or) cell survival mechanisms, possibly involving ERK activation.
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Affiliation(s)
- Akinleye Stephen Akinrinde
- Department of Veterinary Physiology, Biochemistry and Pharmacology, Faculty of Veterinary Medicine, University of Ibadan, 900001 Nigeria
| | - Olutayo Omobowale
- Department of Veterinary Medicine, Faculty of Veterinary Medicine, University of Ibadan, 900001 Nigeria
| | - Ademola Oyagbemi
- Department of Veterinary Physiology, Biochemistry and Pharmacology, Faculty of Veterinary Medicine, University of Ibadan, 900001 Nigeria
| | - Ebunoluwa Asenuga
- Department of Veterinary Biochemistry, Faculty of Veterinary Medicine, University of Benin, Nigeria
| | - Temitayo Ajibade
- Department of Veterinary Physiology, Biochemistry and Pharmacology, Faculty of Veterinary Medicine, University of Ibadan, 900001 Nigeria
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Abstract
Cobalt can cause a distinctive, rapidly progressive and reversible depression of cardiac systolic function, which is readily distinguished from other causes of cardiomyopathy. Patients present with the subacute onset of severe heart failure, which is accompanied by hypotension and cyanosis, pericardial effusion, low voltage on the electrocardiogram, marked elevation of serum enzymes, and lactic acidosis. They typically have a history of lethargy, anorexia, and weight loss in the months preceding the illness and exhibit other evidence of cobalt’s effects on the body (eg, polycythemia and goiter). The course of cobalt-related cardiomyopathy may be progressive and fatal, but those who survive and cease exposure generally demonstrate complete resolution of symptoms and recovery of cardiac function. Patients presenting with rapid onset of cardiomyopathy, who also exhibit polycythemia, pericardial effusion, or goiter should be evaluated for cobalt exposure. Exposure can be confirmed by the measurement of cobalt in the serum, but serum levels of the ion are not reliably predictive of clinical cardiotoxicity. The clinical emergence of cobalt cardiomyopathy seems to require the coexistence of one or more cofactors, particularly a low-protein diet, thiamine deficiency, alcoholism, and hypothyroidism. As the medicinal use of cobalt has waned and measures to reduce industrial exposure have been implemented, subacute cobalt-related cardiomyopathy had become rare. However, reports describing classical features of the disease have recently surged among patients with a malfunctioning cobalt-alloy hip prosthesis.
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Affiliation(s)
- Milton Packer
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX
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Hasegawa M, Naito Y, Yamaguchi T, Miyazaki S, Wakabayashi H, Sudo A. Factors associated with symptomatic pseudotumors following metal-on-metal total hip arthroplasty. BMC Musculoskelet Disord 2016; 17:456. [PMID: 27821101 PMCID: PMC5100170 DOI: 10.1186/s12891-016-1317-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 11/01/2016] [Indexed: 01/07/2023] Open
Abstract
Background Pseudotumors associated with metal-on-metal hips can be symptomatic or asymptomatic. The purpose of this study was to identify the characteristics of pseudotumors associated with pain. Methods A total of 239 large-diameter, metal-on-metal total hip arthroplasties (THAs) were performed in 222 patients. Screening for pseudotumors was performed using magnetic resonance imaging (MRI) in all patients who underwent metal-on-metal THA, and 57 patients with 62 affected hips showed pseudotumors. There were 45 women with 49 hips and 12 men with 13 hips affected, with a mean age of 64 years and a mean body mass index (BMI) of 23.9 kg/m2. Sixteen hips had symptomatic pseudotumors with pain, and 46 hips were asymptomatic. Pseudotumor size was determined. The anatomical position of pseudotumors was divided into anterior position and posterolateral position. Types of pseudotumors were divided into two types: cystic type; and mixed solid cystic and solid type without a cystic component. The follow-up study of pseudotumors was determined using MRI in 33 patients. The serum cobalt and chromium ion levels were measured in 38 patients after unilateral THA. Univariate and multivariate analyses were performed comparing symptomatic and asymptomatic patients to identify the characteristics of symptomatic pseudotumors. Results The mean BMI was 25.4 kg/m2 in symptomatic patients and 23.4 kg/m2 in asymptomatic patients; a higher BMI was associated with symptoms (P = 0.036). Symptomatic pseudotumors were significantly larger (three-fold) than asymptomatic pseudotumors (1812 mm2 vs 642 mm2, P = 0.003). Pseudotumors located in the anterior position were associated with symptoms (P = 0.032), and mixed solid cystic and solid type pseudotumors were associated with symptoms (P = 0.007). A multivariate analysis showed significant differences only in size (R2 = 0.298, P = 0.031). No asymptomatic patients with pseudotumors became symptomatic during the follow-up period of MRI evaluation. Conclusion Larger size was a significant factor for pain on multivariate analysis.
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Affiliation(s)
- Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan.
| | - Yohei Naito
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Toshio Yamaguchi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Shinichi Miyazaki
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Hiroki Wakabayashi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
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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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Lainiala OS, Moilanen TPS, Hart AJ, Huhtala HSA, Sabah SA, Eskelinen AP. Higher Blood Cobalt and Chromium Levels in Patients With Unilateral Metal-on-Metal Total Hip Arthroplasties Compared to Hip Resurfacings. J Arthroplasty 2016; 31:1261-1266. [PMID: 26775067 DOI: 10.1016/j.arth.2015.11.045] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/12/2015] [Accepted: 11/30/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Adverse soft tissue reactions in metal-on-metal (MoM) hip replacements are associated with cobalt (Co) and chromium (Cr) ions in blood. We report the prevalence and risk factors for elevated blood Co and Cr levels in patients with a unilateral MoM hip. METHODS From a single institution, blood Co and Cr levels were analyzed in 1748 patients (692 hip resurfacings and 1056 total hip arthroplasties [THAs]). Concentrations exceeding 7 ppb were considered elevated, and the risk factors for elevated levels were calculated with binary logistic regression. RESULTS Elevated blood metal ion levels were more common in MoM THA than in resurfacing patients (17.4% vs 5.9%, P < .001), and in 5 of the 7 THA brands, more than 20% of patients had elevated metal ion concentrations, whereas the proportion was less than 10% in all hip resurfacings. In resurfacings, small femoral head (odds ratio [OR] 1.30 per millimeter decrease [CI, 1.12-1.49]), high acetabular inclination (OR 1.15 per degree increase [CI 1.09-1.22]), and young age (OR 1.05 per year decrease [1.02-1.10]) were independent risk factors for elevated ions. In the THA group, female gender (OR 2.04 [CI 1.35-3.06]), longer time between surgery and ion measurement (OR 1.19 per year increase [CI 1.05-1.34]), and large headsize (OR 1.07 per millimeter increase [CI 1.01-1.13]) were risk factors for elevated ions. CONCLUSION Given the high percentage of elevated levels, the systematic surveillance of especially large diameter MoM THAs seems justified.
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Affiliation(s)
| | | | - Alister J Hart
- University College London and the Royal National Orthopaedic Hospital, London, UK
| | | | - Shiraz A Sabah
- University College London and the Royal National Orthopaedic Hospital, London, UK
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Hasegawa M, Iino T, Sudo A. Immune response in adverse reactions to metal debris following metal-on-metal total hip arthroplasty. BMC Musculoskelet Disord 2016; 17:221. [PMID: 27209084 PMCID: PMC4875693 DOI: 10.1186/s12891-016-1069-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 05/11/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The purpose of the present study was to determine whether T cell-mediated type IV hypersensitivity reactions could be a major cause of adverse reaction to metal debris (ARMD) after metal-on-metal total hip arthroplasty (THA). METHODS Thirteen patients (1 man and 12 women; mean age 68 years, age range 60 to 83 years) with ARMD underwent revision surgery following metal-on-metal THA (15 hips). Lymphocyte stimulation testing was conducted. Periprosthetic tissue specimens underwent immunohistochemical studies. RESULTS Lymphocyte stimulation testing showed that five patients were nickel-sensitive, and one patient was also cobalt-sensitive. Immunohistochemical studies showed that T cells were dominant in five hips, and B cells were dominant in 10 hips. In four of the five patients with a positive lymphocyte stimulation test, the dominant lymphocytes were T cells, suggesting type IV hypersensitivity. The major cause of ARMD was not type IV hypersensitivity in the remaining nine patients. CONCLUSION Metal hypersensitivity does not appear to be the dominant biological reaction involved in the occurrence of ARMD.
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Affiliation(s)
- Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsuv, Mie, 514-8507, Japan.
| | - Takahiro Iino
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsuv, Mie, 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsuv, Mie, 514-8507, Japan
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Lombardi AV, Berend KR, Adams JB, Satterwhite KL. Adverse Reactions to Metal on Metal Are Not Exclusive to Large Heads in Total Hip Arthroplasty. Clin Orthop Relat Res 2016; 474:432-40. [PMID: 26497881 PMCID: PMC4709305 DOI: 10.1007/s11999-015-4539-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is some suggestion that smaller diameter heads in metal-on-metal total hip arthroplasty (MoM THA) may be less prone to the adverse reactions to metal debris (ARMD) seen with large-diameter heads. QUESTIONS/PURPOSES We reviewed our population of patients with small head (≤ 32 mm) MoM THA to determine (1) the frequency of ARMD; (2) potential risk factors for ARMD in this population; and (3) the etiology of revision and Kaplan-Meier survivorship with revision for all causes. METHODS Small-diameter head MoM devices were used in 9% (347 of 3753) of primary THAs during the study period (January 1996 to March 2005). We generally used these implants in younger, more active, higher-demand patients. Three hundred hips (258 patients) had MoM THA using a titanium modular acetabular component with a cobalt-chromium tapered insert and were available for review with minimum 2-year followup (mean, 10 years; range, 2-19 years). Complete followup was available in 86% of hips (300 of 347). Clinical records and radiographs were reviewed to determine the frequency and etiology of revision. Kaplan-Meier survivorship analysis was performed. RESULTS ARMD frequency was 5% (14 of 300 hips) and represented 70% (14 of 20) of revisions performed. Using multivariate analysis, no variable tested, including height, weight, body mass index, age, cup diameter, cup angle, use of screws, stem diameter, stem type, head diameter, preoperative clinical score, diagnosis, activity level, or sex, was significant as a risk factor for revision. Twenty hips have been revised: two for infection, four for aseptic loosening, and 14 for ARMD. Kaplan-Meier analysis revealed survival free of component revision for all causes was 95% at 10 years (95% confidence interval [CI], 91%-97%), 92% at 15 years (95% CI, 87%-95%), and 72% at 19 years (95% CI, 43%-90%), and survival free of component revision for aseptic causes was 96% at 10 years (95% CI, 92%-98%), 92% at 15 years (95% CI, 88%-95%), and 73% at 19 years (95% CI, 43%-90%). CONCLUSIONS The late onset and devastating nature of metal-related failures is concerning with this small-diameter MoM device. Although the liner is modular, it cannot be exchanged and full acetabular revision is required. Patients with all MoM THA devices should be encouraged to return for clinical and radiographic followup, and clinicians should maintain a low threshold to perform a systematic evaluation. Symptomatic patients should undergo thorough investigation and vigilant observation for ARMD. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Adolph V. Lombardi
- Joint Implant Surgeons, Inc, New Albany, OH USA ,grid.412332.50000000115450811The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.416149.fMount Carmel Health System, New Albany, OH USA ,Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA
| | - Keith R. Berend
- Joint Implant Surgeons, Inc, New Albany, OH USA ,grid.412332.50000000115450811The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.416149.fMount Carmel Health System, New Albany, OH USA
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18
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Trace metal determination as it relates to metallosis of orthopaedic implants: Evolution and current status. Clin Biochem 2016; 49:617-35. [PMID: 26794632 DOI: 10.1016/j.clinbiochem.2016.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 01/01/2016] [Accepted: 01/02/2016] [Indexed: 01/22/2023]
Abstract
In utilising metal surfaces that are in constant contact with each other, metal-on-metal (MoM) surgical implants present a unique challenge, in the sense that their necessity is accompanied by the potential risk of wear particle generation, metal ion release and subsequent patient toxicity. This is especially true of orthopaedic devices that are faulty and subject to failure, where the metal surfaces undergo atypical degradation and release even more unwanted byproducts, as was highlighted by the recent recall of orthopaedic surgical implants. The aim of this review is to examine the area of metallosis arising from the wear of MoM articulations in orthopaedic devices, including how the surgical procedures and detection methods have advanced to meet growing performance and analytical needs, respectively.
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19
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Singh G, Nuechtern JV, Meyer H, Fiedler GM, Awiszus F, Junk-Jantsch S, Bruegel M, Pflueger G, Lohmann CH. Particle characterisation and cytokine expression in failed small-diameter metal-on-metal total hip arthroplasties. Bone Joint J 2015; 97-B:917-23. [DOI: 10.1302/0301-620x.97b7.35163] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The peri-prosthetic tissue response to wear debris is complex and influenced by various factors including the size, area and number of particles. We hypothesised that the ‘biologically active area’ of all metal wear particles may predict the type of peri-prosthetic tissue response. Peri-prosthetic tissue was sampled from 21 patients undergoing revision of a small diameter metal-on-metal (MoM) total hip arthroplasty (THA) for aseptic loosening. An enzymatic protocol was used for tissue digestion and scanning electron microscope was used to characterise particles. Equivalent circle diameters and particle areas were calculated. Histomorphometric analyses were performed on all tissue specimens. Aspirates of synovial fluid were collected for analysis of the cytokine profile analysis, and compared with a control group of patients undergoing primary THA (n = 11) and revision of a failed ceramic-on-polyethylene arthroplasty (n = 6). The overall distribution of the size and area of the particles in both lymphocyte and non-lymphocyte-dominated responses were similar; however, the subgroup with lymphocyte-dominated peri-prosthetic tissue responses had a significantly larger total number of particles. 14 cytokines (interleukin (IL)-1ß, IL-2, IL-4, IL-5, IL-6, IL-10, IL-13, IL-17, interferon (IFN)-γ, and IFN-gamma-inducible protein 10), chemokines (macrophage inflammatory protein (MIP)-1α and MIP-1ß), and growth factors (granulocyte macrophage colony stimulating factor (GM-CSF) and platelet derived growth factor) were detected at significantly higher levels in patients with metal wear debris compared with the control group. Significantly higher levels for IL-1ß, IL-5, IL-10 and GM-CSF were found in the subgroup of tissues from failed MoM THAs with a lymphocyte-dominated peri-prosthetic response compared with those without this response. These results suggest that the ‘biologically active area’ predicts the type of peri-prosthetic tissue response. The cytokines IL-1ß, IL-5, IL-10, and GM-CSF are associated with lymphocyte-dominated tissue responses from failed small-diameter MoM THA. Cite this article: Bone Joint J 2015;97-B:917–23.
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Affiliation(s)
- G. Singh
- National University Health System, 1E
Kent Ridge Road, 119228, Singapore
| | - J. V. Nuechtern
- University of Hamburg-Eppendorf, Martinistrasse
52, D-20246 Hamburg, Germany
| | - H. Meyer
- Otto-von-Guericke University, Leipziger
Strasse 44, D-39120 Magdeburg, Germany
| | - G. M. Fiedler
- Bern University Hospital, F603, CH-3010
Bern, Switzerland
| | - F. Awiszus
- Otto-von-Guericke University, Leipziger
Strasse 44, D-39120 Magdeburg, Germany
| | - S. Junk-Jantsch
- Evangelisches Krankenhaus, Hans-Sachs-Gasse
10-12, A-1180 Vienna, Austria
| | - M. Bruegel
- Ludwig-Maximilians-University, Marchioninistrasse
15, 81377 Munich, Germany
| | - G. Pflueger
- Evangelisches Krankenhaus, Hans-Sachs-Gasse
10-12, A-1180 Vienna, Austria
| | - C. H. Lohmann
- Otto-von-Guericke University, Leipziger
Strasse 44, D-39120 Magdeburg, Germany
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Complications Related to Metal-on-Metal Articulation in Trapeziometacarpal Joint Total Joint Arthroplasty. J Funct Biomater 2015; 6:318-27. [PMID: 26020592 PMCID: PMC4493514 DOI: 10.3390/jfb6020318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 05/18/2015] [Indexed: 02/08/2023] Open
Abstract
Adverse reactions to metal-on-metal (MoM) prostheses are well known from total hip joint resurfacing arthroplasty with elevated serum chrome or cobalt, pain and pseudo tumor formation. It may, however, also be seen after total joint replacement of the trapeziometacarpal joint using MoM articulation, and we present two cases of failure of MoM prostheses due to elevated metal-serum levels in one case and pseudo tumor formation in another case. Furthermore, we suggest a diagnostic algorithm for joint pain after MoM trapeziometacarpal joint replacement based on published experiences from MoM hip prostheses and adverse reactions to metal.
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Muraoka K, Naito M, Nakamura Y, Hagio T, Takano K. Usefulness of ultrasonography for detection of pseudotumors after metal-on-metal total hip arthroplasty. J Arthroplasty 2015; 30:879-84. [PMID: 25540995 DOI: 10.1016/j.arth.2014.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 11/12/2014] [Accepted: 12/02/2014] [Indexed: 02/01/2023] Open
Abstract
We retrospectively analyzed 83 metal-on-metal total hip arthroplasties in 74 patients. Ultrasonography and magnetic resonance imaging (MRI) of each hip were performed to detect abnormal patterns and pseudotumors. We examined the reliability of ultrasonography for detecting pseudotumors in comparison with MRI. We also compared the acetabular component inclination between patients with and without pseudotumors. The mean positive and negative predictive values for pseudotumor detection by ultrasonography were 65% and 91%, respectively. The mean positive and negative likelihood ratios were 5.78 and 0.32, respectively. There was no clear association between pseudotumor presence and acetabular component inclination. We concluded that ultrasonography is a suitable technique to screen for the presence of pseudotumors. We also need to distinguish between bearing-related and taper junction corrosion-related complications.
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Affiliation(s)
- Kunihide Muraoka
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Masatoshi Naito
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Yoshinari Nakamura
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Tomonobu Hagio
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Koichi Takano
- Department of Radiology, Fukuoka University Faculty of Medicine, Fukuoka, Japan
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Bizzotto N, Sandri A, Trivellin G, Magnan B, Micheloni G, Zamò A, Bernardi P, Sbarbati A, Regis D. Chromium-induced diffuse dermatitis with lymph node involvement resulting from Langerhans cell histiocytosis after metal-on-metal hip resurfacing. Br J Dermatol 2015; 172:1633-1636. [PMID: 25385406 DOI: 10.1111/bjd.13517] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2014] [Indexed: 12/01/2022]
Affiliation(s)
- N. Bizzotto
- Department of Orthopaedic and Trauma Surgery; Integrated University Hospital; 37126 Verona Italy
| | - A. Sandri
- Department of Orthopaedic and Trauma Surgery; Integrated University Hospital; 37126 Verona Italy
| | - G. Trivellin
- Department of Orthopaedic and Trauma Surgery; Integrated University Hospital; 37126 Verona Italy
| | - B. Magnan
- Department of Orthopaedic and Trauma Surgery; Integrated University Hospital; 37126 Verona Italy
| | - G.M. Micheloni
- Department of Orthopaedic and Trauma Surgery; Integrated University Hospital; 37126 Verona Italy
| | - A. Zamò
- Department of Pathology and Diagnostics; Section of Pathological Anatomy; University of Verona; Verona Italy
| | - P. Bernardi
- Department of Neurological, Neuropsychological, Morphological and Motor Sciences; Section of Anatomy and Histology; University of Verona; Verona Italy
| | - A. Sbarbati
- Department of Neurological, Neuropsychological, Morphological and Motor Sciences; Section of Anatomy and Histology; University of Verona; Verona Italy
| | - D. Regis
- Department of Orthopaedic and Trauma Surgery; Integrated University Hospital; 37126 Verona Italy
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Bosker BH, Ettema HB, van Rossum M, Boomsma MF, Kollen BJ, Maas M, Verheyen CCPM. Pseudotumor formation and serum ions after large head metal-on-metal stemmed total hip replacement. Risk factors, time course and revisions in 706 hips. Arch Orthop Trauma Surg 2015; 135:417-25. [PMID: 25663048 DOI: 10.1007/s00402-015-2165-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The incidence and natural course of pseudotumors in metal-on-metal total hip arthroplasties is largely unknown. The objective of this study was to identify the true incidence and risk factors of pseudotumor formation in large head metal-on-metal total hip arthroplasties. MATERIALS AND METHODS Incidence, time course and risk factors for pseudotumor formation were analysed after large femoral head MoM-THA. We defined a pseudotumor as a (semi-)solid or cystic peri-prosthetic soft-tissue mass with a diameter ≥2 cm that could not be attributed to infection, malignancy, bursa or scar tissue. All patients treated in our clinic with MoM-THA's were contacted. CT scan, metal ions and X-rays were obtained. Symptoms were recorded. RESULTS After median follow-up of 3 years, 706 hips were screened in 626 patients. There were 228 pseudotumors (32.3 %) in 219 patients (35.0 %). Pseudotumor formation significantly increased after prolonged follow-up. Seventy-six hips (10.8 %) were revised in 73 patients (11.7 %), independent risk factors were identified. Best cutoff point for cobalt and chromium was 4 μg/l (68 and 77 nmol/l). CONCLUSIONS This study confirms a high incidence of pseudotumors, dramatically increasing after prolonged follow-up. Risk factors for pseudotumors are of limited importance. Pain was the strongest predictor for pseudotumor presence; cobalt chromium and swelling were considered poor predictors. Cross-sectional imaging is the main screening tool during follow-up.
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Affiliation(s)
- B H Bosker
- , pc Hoofdstraat 13, 8023, AJ, Zwolle, The Netherlands,
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What are the predictors and prevalence of pseudotumor and elevated metal ions after large-diameter metal-on-metal THA? Clin Orthop Relat Res 2015; 473:477-84. [PMID: 25085361 PMCID: PMC4294930 DOI: 10.1007/s11999-014-3824-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Soft tissue masses, or "pseudotumors," around metal-on-metal total hip arthroplasty (MoM THA) have been reported frequently; however, their prevalence remains unknown. Several risk factors, including elevated metal ion levels, have been associated with the presence of pseudotumor, although this remains controversial. QUESTIONS/PURPOSES The goals of this study were to (1) determine the prevalence of pseudotumors after large-diameter head MoM THA; (2) identify risk factors associated with pseudotumor formation and elevated metal ion levels; and (3) determine the early failure rate of large-diameter MoM THA. METHODS Between December 2005 and November 2012, 258 hips (215 patients) underwent large-diameter head primary MoM THA at our institution. Clinical followup was obtained in 235 hips (91%). Using an inclusion criteria of a minimum followup of 1 year, a subset of 191 hips (mean followup, 4 years; range, 1-7 years) was recruited for high-resolution ultrasound screening for the presence of pseudotumor. Whole blood cobalt and chromium ion levels, UCLA activity level, WOMAC score, patient demographics as well as surgical, implant, and radiographic data were collected. Bivariate correlations and multivariate log-linear regression models were used to compare the presence of pseudotumor and elevated metal ions with all other factors. RESULTS Ultrasound detected a solid, cystic, or mixed mass in 20% hips (38 of 191). No correlation was found between the presence of pseudotumor and any risk factor that we examined. After controlling for confounding variables, elevated cobalt ions were correlated (p<0.001, R=0.50, R2=0.25) with smaller femoral head size, the presence of bilateral MoM THA, and female sex. Elevated chromium ions were correlated (p<0.001, R=0.59, R2=0.34) with smaller femoral head size, presence of bilateral MoM THA, and lower body mass index. The overall survival of MoM THA was 96% at a mean followup of 4.5 years (range, 2-8 years). CONCLUSIONS With the numbers available, we found no associations between the presence of pseudotumor and the potential risk factors we analyzed, including elevated metal ion levels. Further work is needed to explain why larger femoral head sizes resulted in lower metal ion levels despite being associated with higher early failure rates in joint registry data. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Lombardi AV, Berend KR, Morris MJ, Adams JB, Sneller MA. Large-diameter metal-on-metal total hip arthroplasty: dislocation infrequent but survivorship poor. Clin Orthop Relat Res 2015; 473:509-20. [PMID: 25367107 PMCID: PMC4294925 DOI: 10.1007/s11999-014-3976-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 09/22/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Use of large-diameter metal-on-metal (MoM) articulations in THA increased, at least in part, because of the possibility of achieving improved joint stability and excellent wear characteristics in vitro. However, there have been subsequent concerning reports with adverse reactions to metal debris (ARMD), pseudotumors, and systemic complications related to metal ions. QUESTIONS/PURPOSES The purpose of this study was to determine at a minimum of 2 years' followup (1) the proportion of patients who experienced a dislocation; (2) the short-term survivorship obtained with these implants; (3) the causes of failure and the proportion of patients who developed ARMD; and (4) whether there were any identifiable risk factors for revision. METHODS We reviewed the results of 1235 patients who underwent 1440 large-diameter MoM primary THAs at our institution using two acetabular devices from a single manufacturer with minimum 2-year followup. Large-diameter MoM devices were used in 48% (1695 of 3567) of primary THAs during the study period. We generally used these implants in younger, more active, higher-demand patients, in patients considered at higher risk of instability, and in patients with adequate bone stock to achieve stable fixation without use of screws. Clinical records and radiographs were reviewed to determine the incidence and etiology of revision. Patients whose hips were revised were compared with those not revised to identify risk factors; Kaplan-Meier survivorship analysis was performed as was multivariate analysis to account for potential confounding variables when evaluating risk factors. Minimum followup was 2 years (average, 7 years; range, 2-12 years); complete followup was available in 85% of hips (1440 of 1695). RESULTS Dislocation occurred in one hip overall (<1%; one of 1440). Kaplan-Meier analysis revealed survival free of component revision was 87% at 12 years (95% confidence interval, 84%-90%). The two most common indications for revision were ARMD (48%; 47 of 108 hips revised) and loosening or failure of ingrowth (31%; 34 of 108). Risk factors for component revision were younger age at surgery (relative risk [RR] 0.98 per each increased year; p=0.02), higher cup angle of inclination (RR 1.03 per each increased degree; p=0.04), and female sex (RR 1.67; p=0.03). CONCLUSIONS Large-diameter MoM THAs are associated with a very low dislocation rate, but failure secondary to ARMD and loosening or lack of ingrowth occur frequently. Patients with MoM THA should be encouraged to return for clinical and radiographic followup, and clinicians should maintain a low threshold to perform a systematic evaluation. Early diagnosis and appropriate treatment are recommended to prevent the damaging effects of advanced ARMD. LEVEL OF EVIDENCE Level IV, Therapeutic study.
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Affiliation(s)
- Adolph V. Lombardi
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA ,The Ohio State University Wexner Medical Center, Columbus, OH USA ,Mount Carmel Health System, New Albany, OH USA
| | - Keith R. Berend
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA ,The Ohio State University Wexner Medical Center, Columbus, OH USA ,Mount Carmel Health System, New Albany, OH USA
| | - Michael J. Morris
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA ,Mount Carmel Health System, New Albany, OH USA
| | - Joanne B. Adams
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA
| | - Michael A. Sneller
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA
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Tvermoes BE, Paustenbach DJ, Kerger BD, Finley BL, Unice KM. Review of cobalt toxicokinetics following oral dosing: Implications for health risk assessments and metal-on-metal hip implant patients. Crit Rev Toxicol 2015; 45:367-87. [DOI: 10.3109/10408444.2014.985818] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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De Pasquale D, Stea S, Squarzoni S, Bordini B, Amabile M, Catalani S, Apostoli P, Toni A. Metal-on-metal hip prostheses: correlation between debris in the synovial fluid and levels of cobalt and chromium ions in the bloodstream. INTERNATIONAL ORTHOPAEDICS 2015; 38:469-75. [PMID: 24122048 DOI: 10.1007/s00264-013-2137-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 09/19/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE Hip prostheses with metal-on-metal (MoM) coupling can release cobalt-chromium particles and ions. The aim of this work is to verify the correlation between particles in the synovial fluid and circulating ions. METHODS Forty patients were enrolled; particles from synovial fluid were analysed by SEM–EDX (Scanning Electron Microscopy-Energy Dispersion X-rays analysis) and levels of circulating Co and Cr were assayed by ICP-MS (inductively-coupled plasma mass spectrometry). RESULTS In 16 cases we did not find any particles in the synovial fluid and the Co level in whole blood was 0.05–4.42 ppb; in seven with few particles the blood level was 2.2–15.6 ppb; in six cases with several particles the level was 5.0–54.3 ppb; finally, in 11 cases we isolated not only Co-Cr particles, but also Cr particles with low or absent Co and in these patients the circulating level of Co was 23.8–109.6 ppb. Co in serumand Cr level both whole blood and serum have shown a similar trend to Co; the correlation between all these values and the corresponding particles is statistically significant in all cases. CONCLUSION Co and Cr both in serum and whole blood represents a systemic representation of the particle release at local level and can therefore be used to confirm a diagnosis and monitor the wear process of MoM articular prostheses.
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Abstract
BACKGROUND Metal ion release is common following total hip arthroplasty, yet postoperative levels have not been defined for most stems currently used in clinical practice. AIM To assess metal ion release in the serum of patients with well functioning unilateral Exeter V40 primary total hip arthroplasties one year after surgery. METHODS Whole blood chromium and serum cobalt levels were measured in 20 patients following primary total hip arthroplasty with the Exeter V40 stem and a variety of acetabular components one year after surgery. RESULTS Whole blood chromium levels were within the normal range (10-100 nmol/L), with a single mild elevation of serum cobalt (normal <20 nmol/L). CONCLUSIONS In well functioning primary unilateral total hip arthroplasty using the Exeter V40 stem with a variety of acetabular components one year post surgery, whole blood chromium levels are normal and serum cobalt elevations are rare and mild.
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Longitudinal magnetic resonance imaging of pseudotumors following metal-on-metal total hip arthroplasty. J Arthroplasty 2014; 29:2236-8. [PMID: 24931436 DOI: 10.1016/j.arth.2014.05.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/05/2014] [Accepted: 05/09/2014] [Indexed: 02/01/2023] Open
Abstract
The purpose of the study was to determine the natural history of pseudotumors following metal-on-metal total hip arthroplasty (THA) using magnetic resonance imaging (MRI). Initial MRI was conducted at a mean of 36months postoperatively. Follow-up MRI was performed at a mean of 20months after the detection of 24 asymptomatic pseudotumors. Pseudotumor size was determined on MRI. The mean pseudotumor size changed from 729mm(2) to 877mm(2). Pseudotumors increased in size in eight and decreased in six. Ten hips showed no changes. The bigger the pseudotumor size, the more likely the size would increase. In conclusion, pseudotumors frequently change in size. A single MRI study in the clinical decision-making process should be avoided and a longitudinal study should be performed.
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Boeckstyns MEH, Toxvaerd A, Bansal M, Vadstrup LS. Wear particles and osteolysis in patients with total wrist arthroplasty. J Hand Surg Am 2014; 39:2396-404. [PMID: 25227599 DOI: 10.1016/j.jhsa.2014.07.046] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 07/22/2014] [Accepted: 07/23/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the amount of polyethylene debris in the interphase tissue between prosthesis and bone in patients with total wrist arthroplasty correlated with the degree of periprosthetic osteolysis (PPO); and to investigate the occurrence of metal particles in the periprosthetic tissue, the level of chrome and cobalt ions in the blood, and the possible role of infectious or rheumatoid activity in the development of PPO. METHODS Biopsies were taken from the implant-bone interphase in 13 consecutive patients with total wrist arthroplasty and with at least 3 years' follow-up. Serial annual radiographs were performed prospectively for the evaluation of PPO. We collected blood samples for white blood cell count, C-reactive protein, and metallic ion level. RESULTS A radiolucent zone of greater than 2 mm was observed juxta-articular to the radial component in 4 patients and at the carpal component in 3. The magnitude of the radiolucent zone tended to level out over time. We observed subsidence of the implant in 3 patients on the carpal side and in none on the radial side. The amount of polyethylene and metallic debris was generally small and did not correlate with the width of the radiolucent zone. The blood levels of chrome and cobalt ions were normal. There was no evidence of infectious or rheumatoid activity. CONCLUSIONS Polyethylene wear has been accepted as a major cause of osteolysis in total hip arthroplasty, and metallic debris has also been cited to be an underlying cause. However, our hypothesis that polyethylene debris correlated with the degree of PPO could not be confirmed. Also, metallic debris and infectious or rheumatoid activity did not correlate with PPO. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic I.
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Affiliation(s)
- Michel E H Boeckstyns
- Clinic of Hand Surgery, Gentofte Hospital, University of Copenhagen, Denmark, NY; Department of Pathology, Herlev Hospital, University of Copenhagen, Denmark, NY; Department of Pathology, Hospital for Special Surgery, New York, NY.
| | - Anders Toxvaerd
- Clinic of Hand Surgery, Gentofte Hospital, University of Copenhagen, Denmark, NY; Department of Pathology, Herlev Hospital, University of Copenhagen, Denmark, NY; Department of Pathology, Hospital for Special Surgery, New York, NY
| | - Manjula Bansal
- Clinic of Hand Surgery, Gentofte Hospital, University of Copenhagen, Denmark, NY; Department of Pathology, Herlev Hospital, University of Copenhagen, Denmark, NY; Department of Pathology, Hospital for Special Surgery, New York, NY
| | - Lars Soelberg Vadstrup
- Clinic of Hand Surgery, Gentofte Hospital, University of Copenhagen, Denmark, NY; Department of Pathology, Herlev Hospital, University of Copenhagen, Denmark, NY; Department of Pathology, Hospital for Special Surgery, New York, NY
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Lohmann CH, Singh G, Willert HG, Buchhorn GH. Metallic debris from metal-on-metal total hip arthroplasty regulates periprosthetic tissues. World J Orthop 2014; 5:660-666. [PMID: 25405095 PMCID: PMC4133474 DOI: 10.5312/wjo.v5.i5.660] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 06/20/2014] [Accepted: 07/14/2014] [Indexed: 02/06/2023] Open
Abstract
The era of metal-on-metal (MoM) total hip arthroplasty has left the orthopaedic community with valuable insights and lessons on periprosthetic tissue reactions to metallic debris. Various terms have been used to describe the tissue reactions. Sometimes the nomenclature can be confusing. We present a review of the concepts introduced by Willert and Semlitsch in 1977, along with further developments made in the understanding of periprosthetic tissue reactions to metallic debris. We propose that periprosthetic tissue reactions be thought of as (1) gross (metallosis, necrosis, cyst formation and pseudotumour); (2) histological (macrophage-dominated, lymphocyte-dominated or mixed); and (3) molecular (expression of inflammatory mediators and cytokines such as interleukin-6 and tumor necrosis factor-alpha). Taper corrosion and modularity are discussed, along with future research directions to elucidate the antigen-presenting pathways and material-specific biomarkers which may allow early detection and intervention in a patient with adverse periprosthetic tissue reactions to metal wear debris.
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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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Koper MC, Mathijssen NMC, van Ravenswaay Claasen HH, Witt F, Morlock MM, Vehmeijer SBW. Pseudotumor After Bilateral Ceramic-on-Metal Total Hip Arthroplasty: A Case Report. JBJS Case Connect 2014; 4:e25. [PMID: 29252511 DOI: 10.2106/jbjs.cc.m.00209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- M C Koper
- Department of Orthopedics (M.C.K., N.M.C.M., and S.B.W.V.) and Pathology (H.H.v.R.C.), Reinier de Graaf Hospital, Reinier de Graafweg 3, 2625 AD Delft, The Netherlands.
| | - N M C Mathijssen
- Department of Orthopedics (M.C.K., N.M.C.M., and S.B.W.V.) and Pathology (H.H.v.R.C.), Reinier de Graaf Hospital, Reinier de Graafweg 3, 2625 AD Delft, The Netherlands.
| | - H H van Ravenswaay Claasen
- Department of Orthopedics (M.C.K., N.M.C.M., and S.B.W.V.) and Pathology (H.H.v.R.C.), Reinier de Graaf Hospital, Reinier de Graafweg 3, 2625 AD Delft, The Netherlands.
| | - F Witt
- Biomechanics Section, Hamburg University of Technology, Denickestraße 15, 21073 Hamburg, Germany. .
| | - M M Morlock
- Biomechanics Section, Hamburg University of Technology, Denickestraße 15, 21073 Hamburg, Germany. .
| | - S B W Vehmeijer
- Department of Orthopedics (M.C.K., N.M.C.M., and S.B.W.V.) and Pathology (H.H.v.R.C.), Reinier de Graaf Hospital, Reinier de Graafweg 3, 2625 AD Delft, The Netherlands.
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Chen Z, Wang Z, Wang Q, Cui W, Liu F, Fan W. Changes in early serum metal ion levels and impact on liver, kidney, and immune markers following metal-on-metal total hip arthroplasty. J Arthroplasty 2014; 29:612-6. [PMID: 23993737 DOI: 10.1016/j.arth.2013.07.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 07/22/2013] [Accepted: 07/24/2013] [Indexed: 02/01/2023] Open
Abstract
We retrospectively studied 32 consecutive patients (32 hips) who underwent THA with a Durom large-head, MOM articulation between January 2008 and December 2010. Of the patients who underwent THA using a Trilogy metal on polyethylene prosthesis during the same period, 32 were chosen to form the Trilogy group. 32 volunteers were chosen to form the control group. At the last follow-up, serum metal ion levels, liver and kidney function and host immunologic immune responses were evaluated. The mean Co and Cr levels in the Durom group were 4.33- and 1.95-fold higher than those in the Trilogy group. CD3+, CD4+ and CD8+ cell levels in the Durom group were significantly decreased. The INF-γ level in the Durom group was significantly higher than that in the Trilogy and control groups.
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Affiliation(s)
- Zhefeng Chen
- Department of Orthopedics, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Zhen Wang
- Department of Orthopedics, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Qing Wang
- Department of Orthopedics, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Weiding Cui
- Department of Orthopedics, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Feng Liu
- Department of Orthopedics, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Weimin Fan
- Department of Orthopedics, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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Sugano N, Iida H, Akiyama H, Takatori Y, Nagoya S, Hasegawa M, Kabata T, Hachiya Y, Yasunaga Y. Nationwide investigation into adverse tissue reactions to metal debris after metal-on-metal total hip arthroplasty in Japan. J Orthop Sci 2014; 19:85-9. [PMID: 24338047 DOI: 10.1007/s00776-013-0490-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 10/12/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adverse reactions to metal debris (ARMD) after receiving metal-on-metal (MoM) hip implants is a recent concern. However, no epidemiologic study has examined ARMD for MoM hip implants in Japan. The purposes of this study were to research the incidence of ARMD and to identify poorly performing MoM hip implants in Japan. METHODS From 2000 to 2011, 7 companies provided 23,226 MoM implants in Japan. A questionnaire regarding ARMD was sent to 101 hospitals at which 62% of the 23,226 MoM implants had been used. RESULTS Replies to the questionnaire were received from 82 hospitals. In these hospitals, surface hip replacement types (SRs) were used in 606 hips and stemmed types were used in 12,961 hips. ARMD were reported in 3 hips (0.5%) with SRs and 160 hips (1.2%) with stemmed types. ARMD in the 3 hips with SRs were asymptomatic and no revisions were performed. Among AMRD with stemmed implants, revision was performed in 83 hips and excision of an ARMD lesion was performed in 3 hips. The remaining 74 hips were asymptomatic and careful follow-up was continued. A significant difference in reoperation rate was evident between SRs (0%) and stemmed types (0.7%). Incidences of ARMD were significantly higher with Ultamet (P = 0.005), Conserve (P < 0.001), and Cormet (P < 0.001) MoM bearing couples than with Metasul bearings. CONCLUSIONS The incidence of ARMD in large surgical volume hospitals in Japan from 2000 to 2011 was estimated to be 0.5% with SRs and 1.2% with stemmed types. The reoperation rate was significantly higher with stemmed types than with SRs. Three brands of MoM stemmed implants were identified as showing a higher incidence of ARMD.
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Affiliation(s)
- Nobuhiko Sugano
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Yamadaoka 2-2 Suita, Osaka, 565-0871, Japan,
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Chang EY, McAnally JL, Van Horne JR, Van Horne JG, Wolfson T, Gamst A, Chung CB. Relationship of plasma metal ions and clinical and imaging findings in patients with ASR XL metal-on-metal total hip replacements. J Bone Joint Surg Am 2013; 95:2015-20. [PMID: 24257659 DOI: 10.2106/jbjs.l.01481] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Plasma metal ion levels are commonly used in the postoperative follow-up evaluation of patients who have had a metal-on-metal hip arthroplasty. However, the relationship between these levels and clinical and imaging findings is not well known. METHODS We evaluated 156 consecutive patients who received a unilateral ASR XL total hip replacement. Patients presented, regardless of symptoms, in response to a voluntary recall of the hip replacement by the manufacturer and were assessed with regard to the presence and type of symptoms and plasma cobalt-chromium levels. In addition, radiographic and magnetic resonance imaging studies were performed and analyzed. RESULTS Eighty patients were asymptomatic, and seventy-six patients were symptomatic. The median cobalt level was 1.8 ppb, and the median chromium level was 1.0 ppb (at or below measurement threshold). Pseudotumors that could be detected on magnetic resonance imaging were seen in 69% (107) of 156 patients, and radiographic osteolysis was evident in 7% (eleven patients). At a threshold of 5 ppb, no association was detected between abnormal metal ion levels and patient symptoms, prosthetic femoral head size, or acetabular cup inclination. An abnormal cobalt level was significantly associated with the presence of periprosthetic lucency on radiographs and pseudotumor on magnetic resonance imaging (p < 0.05). An abnormal chromium level showed a similar pattern, but the relationships did not reach significance. Both abnormal plasma cobalt and chromium levels were associated with larger sizes of pseudotumor when present (p < 0.05). CONCLUSIONS In our sample, with a threshold of 5 ppb, abnormal plasma metal ions were associated with larger sizes of pseudotumors when present, but were not predictive of patient symptoms. Abnormal plasma cobalt levels have a significant association with periprosthetic lucency and presence of pseudotumor. Plasma chromium shows a similar pattern of association with lucency and presence of pseudotumor, although the relationships were not significant. Metal ion analysis should be used in conjunction with clinical and imaging evaluation and not as a sole indirect screening test when evaluating patients following metal-on-metal hip arthroplasty.
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Affiliation(s)
- Eric Y Chang
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161
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Hansen TB, Dremstrup L, Stilling M. Patients with metal-on-metal articulation in trapeziometacarpal total joint arthroplasty may have elevated serum chrome and cobalt. J Hand Surg Eur Vol 2013; 38:860-5. [PMID: 23677963 DOI: 10.1177/1753193413487685] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Serum chrome and cobalt was measured in 50 patients with trapeziometacarpal total joint replacement with metal-on-metal articulation and compared with serum chrome and cobalt values in 23 patients with trapeziometacarpal total joint replacement with metal-on-polyethylene articulation. In 10 of 50 (20%) patients with metal-on-metal articulation, slightly elevated serum chrome or cobalt values were found compared with only one in 23 (4%) patients with metal-on-polyethylene articulation. All metal values were lower than accepted 'normal values' for metal-on-metal hip arthroplasty and so considered not to be a general health risk. However, the mean disabilities of the arm, shoulder and hand (DASH) score was 24 in patients with elevated serum chrome or cobalt compared with 10 in patients with normal metal values (p < 0.05) suggesting a local clinical effect of the elevated serum chrome or cobalt values. We recommend that patients with trapeziometacarpal total joint replacement with metal-on-metal articulation are followed with DASH score and radiological examination every 3-5 years and serum chrome and cobalt should be analysed in symptomatic cases to learn more about possible local complications leading to, or arising from, metal debris.
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Affiliation(s)
- T B Hansen
- Department of Orthopaedics, Regional Hospital Holstebro, Lægårdvej, Denmark
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Jantzen C, Jørgensen HL, Duus BR, Sporring SL, Lauritzen JB. Chromium and cobalt ion concentrations in blood and serum following various types of metal-on-metal hip arthroplasties: a literature overview. Acta Orthop 2013; 84:229-36. [PMID: 23594249 PMCID: PMC3715816 DOI: 10.3109/17453674.2013.792034] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Widely different metal ion concentrations in blood and serum have been reported with metal-on-metal (MoM) implants. We reviewed the literature on blood and serum ion concentrations of chromium (Cr) and cobalt (Co) following various MoM hip arthroplasties. METHODS Studies were searched for in the Medline database, Embase, and the Cochrane Database of Systematic Reviews. Highest mean or median ion concentrations of Cr and Co after a minimum of 1 year of follow-up were extracted and grouped according to sample- and articulation type, and average values were calculated. RESULTS 43 studies were included and 16 different MoM implants were identified. For the different types of bearings, average ion concentrations and range were calculated from the mean or median ion concentration. The average Cr concentration ranged between 0.5 and 2.5 μg/L in blood and between 0.8 and 5.1 μg/L in serum. For Co, the range was 0.7-3.4 μg/L in blood and 0.3-7.5 μg/L in serum. INTERPRETATION When the average blood ion concentrations calculated for the different implants, together with the concentrations measured in the individual studies, were compared with the upper acceptable limit for Cr and Co in blood, no clear pattern was recognized. Furthermore, we were unable to detect any clear difference in ion concentrations between different types of implants (THA and resurfacing).
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Affiliation(s)
| | - Henrik L Jørgensen
- Clinical Biochemistry, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Paustenbach DJ, Tvermoes BE, Unice KM, Finley BL, Kerger BD. A review of the health hazards posed by cobalt. Crit Rev Toxicol 2013; 43:316-62. [DOI: 10.3109/10408444.2013.779633] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Hasegawa M, Yoshida K, Wakabayashi H, Sudo A. Prevalence of adverse reactions to metal debris following metal-on-metal THA. Orthopedics 2013; 36:e606-12. [PMID: 23672913 DOI: 10.3928/01477447-20130426-23] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to determine the prevalence of adverse reactions to metal debris (ARMD) following large-diameter metal-on-metal total hip arthroplasty. The authors examined the potential for using magnetic resonance imaging to screen for pseudotumors in 108 hips 2 years postoperatively. Serum cobalt and chromium concentrations were measured in 80 hips that underwent unilateral total hip arthroplasty. The authors considered pseudotumors and aseptic lymphocyte-dominated vasculitis-associated lesions to be ARMD and compared metal ion levels between hips with ARMD (ARMD group) with hips with no ARMD (non-ARMD group). Magnetic resonance imaging revealed pseudotumors in 9 patients (10 hips, 9%). Five of these 10 hips were symptomatic and underwent revision surgery. Two other patients underwent revision surgery due to symptomatic cup loosening with aseptic lymphocyte-dominated vasculitis-associated lesions. Ten patients (12 hips) had ARMD. Serum cobalt and chromium concentrations were significantly higher in hips with ARMD than hips without ARMD. Other factors, including age, body mass index, sex, clinical score, acetabular cup inclination angle, and femoral head diameter, were not significantly different between the groups. Elevated metal ion levels suggest that ARMD is associated with increased metal wear. Magnetic resonance imaging provides sensitive screening for pseudotumors following metal-on-metal total hip arthroplasty.
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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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Singh G, Meyer H, Ruetschi M, Chamaon K, Feuerstein B, Lohmann CH. Large-diameter metal-on-metal total hip arthroplasties: a page in orthopedic history? J Biomed Mater Res A 2013; 101:3320-6. [PMID: 23529961 DOI: 10.1002/jbm.a.34619] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/22/2013] [Accepted: 01/23/2013] [Indexed: 01/31/2023]
Abstract
Large-diameter metal-on-metal (MoM) bearings evolved from the success of hip resurfacing. These implants were used in revision surgery in cases with well-fixed acetabular cups but loose or failed femoral stems, to avoid cup revision. Early data showed low rates of dislocation and potentially low wear profiles due to better fluid film lubrication. The risk of impingement was also thought to be low due to the increased head-neck ratio. Subsequently large-diameter MoM heads gained popularity in primary hip replacement. Recent data has emerged on the unacceptably high revision rates among patients with large-diameter MoM total hip arthroplasties (THAs), high blood levels of metal ions, and adverse tissue reactions. The head-neck (cone-taper) modular interface probably represents the weak link in large metal heads that have been used on conventional tapers. Increased torque of the large head, micromotion, and instability at the cone-taper interface, synergistic interactions between corrosion and wear, edge loading, low clearance, and psoas impingement are the likely causes for early failure of these prostheses.
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Affiliation(s)
- Gurpal Singh
- Department of Orthopedic Surgery, Otto-Von-Guericke University, Leipziger Str. 44, D-39120, Magdeburg, Germany; University Orthopedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
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Cooper HJ, Jacobs JJ, Leikin JB, Barden RM, Rosenberg AG. Elevated Serum Metal Levels from Vitamin Supplementation: A Case Report. JBJS Case Connect 2013; 3:e18. [PMID: 29252323 DOI: 10.2106/jbjs.cc.l.00211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- H John Cooper
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612.
| | - Joshua J Jacobs
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612.
| | - Jerrold B Leikin
- NorthShore University HealthSystem, 2150 Pfingsten Road, Glenview, IL 60026
| | - Regina M Barden
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612.
| | - Aaron G Rosenberg
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612.
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Fritzsche J, Borisch C, Schaefer C. Case report: High chromium and cobalt levels in a pregnant patient with bilateral metal-on-metal hip arthroplasties. Clin Orthop Relat Res 2012; 470:2325-31. [PMID: 22692823 PMCID: PMC3392404 DOI: 10.1007/s11999-012-2398-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 05/10/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Metal-on-metal bearings frequently are used in young patients leading to the concern that disseminated metals such as chromium (Cr) and cobalt (Co) as the main constituents could affect pregnancies. CASE DESCRIPTION We describe a 41-year-old patient with bilateral metal-on-metal hip arthroplasties, a recurrent pseudotumor, and extremely high blood levels (Cr 39 μg/L, Co 138 μg/L) at 12 gestational weeks. At different gestational weeks, maternal blood, aspirate of the pseudotumor, and amniotic fluid were analyzed for Cr and Co. Therapy with chelating agents was not recommended because the mother showed no symptoms of toxicity and the safety of chelating therapy during pregnancy is not established. At 38 weeks of gestation, a healthy male infant was delivered with elevated Cr and Co cord blood levels. At the age of 8 weeks, the infant's Cr was comparable to the cord blood level, whereas the Co decreased considerably without treatment. At the age of 14 weeks, the infant's development was seemingly uneventful and no signs of toxicity were obvious. LITERATURE REVIEW Carcinogenic, mutagenic, and teratogenic potentials of these metals have been suggested. However, we found no published clinical observations in context with pregnancies of women with hip arthroplasties using metal-on-metal implants. To our knowledge, this is the first report of such high levels of Cr and Co in a human pregnancy. PURPOSES AND CLINICAL RELEVANCE Although we cannot generalize from one case, the seemingly uneventful outcome of this pregnancy may reassure colleagues when counseling patients with high ion levels whether to carry a pregnancy to term.
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Affiliation(s)
- Juliane Fritzsche
- Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie (Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy), Institut für Klinische Pharmakologie und Toxikologie, Charité Universitätsmedizin Berlin, Spandauer Damm 130, Haus 10, D-14050 Berlin, Germany
| | - Cornelia Borisch
- Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie (Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy), Institut für Klinische Pharmakologie und Toxikologie, Charité Universitätsmedizin Berlin, Spandauer Damm 130, Haus 10, D-14050 Berlin, Germany
| | - Christof Schaefer
- Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie (Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy), Institut für Klinische Pharmakologie und Toxikologie, Charité Universitätsmedizin Berlin, Spandauer Damm 130, Haus 10, D-14050 Berlin, Germany
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