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Freund SS, Thorn APJ, Puri A, Petersen MM, Baad-Hansen T. Elevated cobalt levels in metal-on-polyethylene knee megaprostheses: a prospective 1-year cohort study of 56 patients with hip and knee megaprostheses. Acta Orthop 2024; 95:174-179. [PMID: 38629902 PMCID: PMC11022749 DOI: 10.2340/17453674.2024.40502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/13/2023] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND AND PURPOSE Concerns have emerged regarding elevated levels of cobalt and chromium in patients with metal-on-metal megaprostheses. This prospective study aims to identify systemic cobalt and chromium levels in metal-on-polyethylene knee and hip megaprostheses and their associations with other factors. METHODS 56 patients underwent knee or hip megaprosthesis surgery at 2 sarcoma centers. Serum cobalt and chromium levels were measured preoperatively and thrice within the first year using inductively coupled plasma mass spectrometry. RESULTS A statistically significant difference in serum cobalt levels (1.4 ppb; 95% confidence interval [CI] 0.0-3.3) was observed 1 year after knee megaprosthesis surgery compared with preoperative levels. In contrast no difference in chromium levels was observed after 1 year compared with preoperative levels (0.05 ppb; CI 0.0-0.8). An association between younger age, higher eGFR, and increased cobalt levels was observed. No significant correlations were found between ion levels and resection length or the number of modular connections. CONCLUSION We found elevated serum ion levels in metal-on-polyethylene knee megaprostheses in contrast to metal-on-polyethylene hip megaprostheses. Furthermore, a positive correlation between cobalt and chromium levels, and between cobalt and eGFR was identified, along with a negative correlation between cobalt and age. This study highlights the importance of monitoring systemic cobalt and chromium levels in patients with megaprostheses.
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Affiliation(s)
| | - Andrea Pohly Jeppesen Thorn
- Musculoskeletal Tumor Section of the Department of Orthopedic Surgery, Rigshospitalet - University of Copenhagen, Denmark
| | - Ajay Puri
- Orthopedic Oncology, Tata Memorial Centre, HBNI, Mumbai, India
| | - Michael Mørk Petersen
- Musculoskeletal Tumor Section of the Department of Orthopedic Surgery, Rigshospitalet - University of Copenhagen, Denmark
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Bunyoz KI, Tsikandylakis G, Mortensen K, Gromov K, Mohaddes M, Malchau H, Troelsen A. No difference in whole-blood metal ions between 32-mm and 36- to 44-mm femoral heads in metal-on-polyethylene total hip arthroplasty: a 2-year report from a randomised control trial. Hip Int 2023; 33:184-192. [PMID: 34102902 DOI: 10.1177/11207000211022623] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM To investigate the effect of femoral head size on blood metal-ion levels caused by taper corrosion in metal-on-polyethylene total hip arthroplasty, comparing 36- to 44-mm heads with 32-mm heads. METHODS In a randomised, controlled, single-blinded trial, 96 patients were allocated to receive either a 32-mm metal head or the largest possible metal head (36-44 mm) that could be accommodated in the thinnest available vitamin E, cross-linked polyethylene insert. Blood metal ion levels were collected at 1- and 2-year follow-ups. RESULTS At 1-year, metal-ion levels did not differ between the groups. The median (interquartile range) blood-ion levels for the 32-mm versus the 36- to 44-mm group were 0.11 µg/L (0.08-0.15) versus 0.12 µg/L (0.08-0.22), p = 0.546, for cobalt, 0.50 µg/L (0.50-0.59) versus 0.50 µg/L (0.50-1.20), p = 0.059, for chromium and 1.58 µg/L (1.38-2.05) versus 1.48 µg/L (1.14-1.87), p = 0.385, for titanium. At 2 years, there was no difference either and the corresponding values were 0.15 µg/L (0.12-0.24) versus 0.18 µg/L (0.12-0.28), p = 0.682 for cobalt, 0.50 µg/L (0.50-0.50) versus 0.50 µg/L (0.50-0.57), p = 0.554, for chromium and 1.54 µg/L (1.16-1.87) versus 1.42 µg/L (1.01-1.72), p = 0.207 for titanium. CONCLUSIONS The use of the largest possible metal head (36-44 mm) compared to a 32-mm head in metal-on-polyethylene bearings does not appear to elevate blood metal-ion levels up to 2 years postoperatively. As taper corrosion is probably time-dependent, longer-term reports are needed to evaluate the association between large metal heads and blood metal ion levels.Trial registration: ClinicalTrials.gov (reg. ID NCT0231 6704).
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Affiliation(s)
- Kristine I Bunyoz
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Georgios Tsikandylakis
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Kristian Mortensen
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Maziar Mohaddes
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Henrik Malchau
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.,Harris Orthopaedic Laboratory, Department of Orthopaedics, Massachusetts General Hospital, Boston, USA
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
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Eltit F, Mohammad N, Medina I, Haegert A, Duncan CP, Garbuz DS, Greidanus NV, Masri BA, Ng TL, Wang R, Cox ME. Perivascular lymphocytic aggregates in hip prosthesis-associated adverse local tissue reactions demonstrate Th1 and Th2 activity and exhausted CD8 + cell responses. J Orthop Res 2021; 39:2581-2594. [PMID: 33506972 DOI: 10.1002/jor.24998] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 01/19/2021] [Accepted: 01/24/2021] [Indexed: 02/04/2023]
Abstract
Hip implants are a successful solution for osteoarthritis; however, some individuals with metal-on-metal (MoM) and metal-on-polyethylene (MoP) prosthetics develop adverse local tissue reactions (ALTRs). While MoM and MoP ALTRs are presumed to be delayed hypersensitivity reactions to corrosion products, MoM- and MoP-associated ALTRs present with different histological characteristics. We compared MoM- and MoP-associated ALTRs histopathology with cobalt and chromium levels in serum and synovial fluid. We analyzed the gene expression levels of leukocyte aggregates and synovial fluid chemokines/cytokines to resolve potential pathophysiologic differences. In addition, we classified ALTRs from 79 patients according to their leukocyte infiltrates as macrophage-dominant, mixed, and lymphocyte-dominant. Immune-related transcript profiles from lymphocyte-dominant MoM- and MoP-associated ALTR patients with perivascular lymphocytic aggregates were similar. Cell signatures indicated predominantly macrophage, Th1 and Th2 lymphocytic infiltrate, with strong exhausted CD8+ signature, and low Th17 and B cell, relative to healthy lymph nodes. Lymphocyte-dominant ALTR-associated synovial fluid contained higher levels of induced protein 10 (IP-10), interleukin-1 receptor antagonist (IL-1RN), IL-8, IL-6, IL-16, macrophage inflammatory protein 1 (MIP-1α), IL-18, MCP-2, and lower cell-attracting chemokine levels, when compared with prosthetic revisions lacking ALTRs. In addition, the higher levels of IP-10, IL-8, IL-6, MIP-1α, and MCP-2 were observed within the synovial fluid of the lymphocyte-dominant ALTRs relative to the macrophage-dominant ALTRs. Not all cytokines/chemokines were detected in the perivascular aggregate transcripts, suggesting the existence of other sources in the affected synovia. Our results support the hypothesis of common hypersensitivity pathogenesis in lymphocyte-dominant MoM and MoP ALTRs. The exhausted lymphocyte signature indicates chronic processes and an impaired immune response, although the cause of the persistent T-cell activation remains unclear. The cytokine/chemokine signature of lymphocyte-dominant-associated ATLRs may be of utility for diagnosing this more aggressive pathogenesis.
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Affiliation(s)
- Felipe Eltit
- Department of Materials Engineering, University of British Columbia, Vancouver, British Columbia, Canada.,School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver Prostate Centre, Vancouver, British Columbia, Canada
| | - Nissreen Mohammad
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Anne Haegert
- Vancouver Prostate Centre, Vancouver, British Columbia, Canada
| | - Clive P Duncan
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald S Garbuz
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Hip Health and Mobility, Vancouver, British Columbia, Canada
| | - Nelson V Greidanus
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Hip Health and Mobility, Vancouver, British Columbia, Canada
| | - Tony L Ng
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rizhi Wang
- Department of Materials Engineering, University of British Columbia, Vancouver, British Columbia, Canada.,School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Hip Health and Mobility, Vancouver, British Columbia, Canada
| | - Michael E Cox
- Vancouver Prostate Centre, Vancouver, British Columbia, Canada.,Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Manninen E, Lainiala O, Karsikas M, Reito A, Jämsä P, Eskelinen A. Do cobalt or chromium accumulate in metal-on-metal hip arthroplasty patients who have mild, moderate, or severe renal insufficiency? Bone Joint J 2021; 103-B:1231-1237. [PMID: 34192941 DOI: 10.1302/0301-620x.103b7.bjj-2020-0836.r2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To find out if there is an inverse association between estimated glomerular filtration rate (eGFR) and whole blood cobalt (Co) and chromium (Cr) levels in patients with metal-on-metal (MoM) hip arthroplasties and renal insufficiency, suggesting that renal insufficiency could cause accumulation of Co and Cr in blood. METHODS Out of 2,520 patients with 3,013 MoM hip arthroplasties, we identified 1,244 patients with whole blood Co, Cr, and creatinine measured within no more than a one-year interval. We analyzed the correlation of blood metal ion levels and eGFR to identify a potential trend of accumulating Co or Cr with decreasing eGFR. RESULTS Of the 1,244 patients, 112 had normal renal function (eGFR > 90 ml/min/1.73 m2), 715 had mild renal insufficiency (eGFR 60 to 89), 384 had moderate renal insufficiency (eGFR 30 to 59), 27 had severe renal insufficiency (eGFR 15 to 29), and six had end-stage renal insufficiency (eGFR < 15). Median eGFR was 68 ml/min/1.73 m2 (interquartile range (IQR) 56 to 82), median whole blood Co was 3.3 µg/l (IQR 1.1 to 9.9), and median Cr was 2.0 µg/l (IQR 1.2 to 3.6). We did not observe an association between decreased eGFR and increased whole blood Co and Cr concentrations, but instead both increased Co and Cr were associated with higher eGFR, indicating better kidney function. CONCLUSION As patients with MoM hip arthroplasties get older, the prevalence of renal insufficiency among them will increase, and orthopaedic surgeons will increasingly have to evaluate whether or not this affects patient follow-up. The USA Food and Drug Administration suggests that closer follow-up may be needed for MoM patients with renal insufficiency. We did not observe accumulation of blood Co or Cr in MoM hip arthroplasty patients with mild to severe renal insufficiency. Cite this article: Bone Joint J 2021;103-B(7):1231-1237.
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Affiliation(s)
- Eveliina Manninen
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland
| | - Olli Lainiala
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland.,Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Mari Karsikas
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland.,Center For Life Course Health Research, University of Oulu, Oulu, Finland
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland
| | - Pyry Jämsä
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland
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Course of Metal Ions after a Revision of Malfunctioning Metal-on-Metal Total Hip Prostheses. ACTA ACUST UNITED AC 2021; 57:medicina57020115. [PMID: 33525335 PMCID: PMC7912175 DOI: 10.3390/medicina57020115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 12/16/2022]
Abstract
The present research evaluated the course of cobalt and chromium in the blood and urine after the revision of metal-on-metal with a ceramic-on-polyethylene total hip arthroplasty. Seven patients were enrolled for hip prosthesis revision owing to ascertained damage of the implant. Metals in the blood and urine were evaluated before and after the hip revision. The double measurement before the total hip revision revealed high levels of metal ions (on average, 88.1 µg/L of cobalt in the blood, 399.0 µg/g of creatinine cobalt in the urine, 46.8 µg/L of chromium in the blood, and 129.6 µg/g of creatinine chromium in the urine at the first measurements), with an increasing trend between the first and second dosage. Within a week after the hip revision, the levels of metal ions significantly decreased by approximately half. Four to six months after the operation, the cobalt levels were found near to the reference values, whereas the chromium levels reached 25% of the values measured before the revision. The revision of malfunctioning metal-on-metal implants produced a dramatic decrease of metal ions in biological fluids, although it did not completely rescue the chromium level.
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O'Keefe R, Hopkins C, Qin L. Clinician-directed treatment guidelines. J Orthop Translat 2020; 20:3. [PMID: 31908927 PMCID: PMC6939104 DOI: 10.1016/j.jot.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Regis O'Keefe
- Department of Orthopaedic Surgery, Washington University School of Medicine, Missouri, USA
- Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Hong Kong Special Administrative Region
- Musculoskeletal Research Laboratory and Innovative Orthopaedic Biomaterials and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
- Translational Medicine Research and Development Center, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, PR China
| | - Chelsea Hopkins
- Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Hong Kong Special Administrative Region
- Musculoskeletal Research Laboratory and Innovative Orthopaedic Biomaterials and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
- Translational Medicine Research and Development Center, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, PR China
| | - Ling Qin
- Musculoskeletal Research Laboratory and Innovative Orthopaedic Biomaterials and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
- Translational Medicine Research and Development Center, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, PR China
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