Levels of systemic metal ions in patients with intramedullary nails

Titanium Alloy Intramedullary Nails and Plates Affect Serum Metal Ion Levels within the Fracture Healing Period

Titanium alloy implants are the most used materials for the fixation of lower extremity fractures. Although these implants were thought to be inert materials in vitro, several studies have shown increased serum and remote tissue metal ion levels due to wear of implants and friction of the bone-implant interface in vivo. The aim of this study was to investigate the alteration of serum metal ion levels that are released from intramedullary nails and plates used for the fixation of lower extremity fractures, within the fracture healing period. The study included 20 adult patients, who were treated with intramedullary nail or plate osteosynthesis due to closed lower extremity fractures. Alterations of serum titanium, aluminum, molybdenum, and vanadium levels were evaluated at 6, 12, 18, and 24 weeks postoperatively. A statistically significant increase was determined in serum titanium, aluminum, molybdenum, and vanadium ion levels in the intramedullary nail and plate groups at the end of the follow-up period. Pairwise comparisons of metal ion levels between implant groups revealed no significant difference during a 24-week follow-up period. Compared to the control group, statistically significant increased levels of serum titanium, aluminum, vanadium, and molybdenum ions were determined in the implant groups used for the fixation of lower extremity fractures at the end of 24 weeks. In the current literature, the potential toxic effects of prolonged exposure to low levels of these metal ions are still unknown. It can be predicted that long-term metal ion exposure could result in vivo pathological processes in the future.

Titanium Alloys for Dental Implants: A Review

The topic of titanium alloys for dental implants has been reviewed. The basis of the review was a search using PubMed, with the large number of references identified being reduced to a manageable number by concentrating on more recent articles and reports of biocompatibility and of implant durability. Implants made mainly from titanium have been used for the fabrication of dental implants since around 1981. The main alloys are so-called commercially pure titanium (cpTi) and Ti-6Al-4V, both of which give clinical success rates of up to 99% at 10 years. Both alloys are biocompatible in contact with bone and the gingival tissues, and are capable of undergoing osseointegration. Investigations of novel titanium alloys developed for orthopaedics show that they offer few advantages as dental implants. The main findings of this review are that the alloys cpTi and Ti-6Al-4V are highly satisfactory materials, and that there is little scope for improvement as far as dentistry is concerned. The conclusion is that these materials will continue to be used for dental implants well into the foreseeable future.

Improving the Tribological Properties and Biocompatibility of Zr-Based Bulk Metallic Glass for Potential Biomedical Applications

Zr-based bulk metallic glasses (Zr-BMGs) are potentially the next generation of metallic biomaterials for orthopaedic fixation devices and joint implants owing to their attractive bulk material properties. However, their poor tribological properties and long-term biocompatibility present major concerns for orthopaedic applications. To this end, a novel surface modification technology, based on ceramic conversion treatment (CCT) in an oxidising medium between the glass transition temperature and the crystallisation temperature, has been developed to convert the surface of commercially available Zr₄₄Ti₁₁Cu₁₀Ni₁₁Be₂₅ (Vitreloy 1b) BMG into ceramic layers. The engineered surfaces were fully characterised by in-situ X-ray diffraction, glow-discharge optical emission spectroscopy, scanning electron microscopy, transmission electron microscopy, and scanning transmission electron microscopy. The mechanical, chemical, and tribological properties were evaluated respectively by nano-indentation, electrochemical corrosion testing, tribological testing and the potential biocompatibility assessed by a cell proliferation assay. The results have demonstrated that after CCT at 350 °C for 40 h and at 380 °C for 4.5 h the original surfaces were converted into to a uniform 35–55-nm-thick oxide layer (with significantly reduced Ni and Cu concentration) followed by a 200–400-nm-thick oxygen-diffusion hardened case. The surface nano hardness was increased from 7.75 ± 0.36 to 18.32 ± 0.21 GPa, the coefficient of friction reduced from 0.5–0.6 to 0.1–0.2 and the wear resistance improved by more than 60 times. After 24 h of contact, SAOS-2 human osteoblast-like cells had increased surface coverage from 18% for the untreated surface to 46% and 54% for the 350 °C/40 h and 380 °C/4.5 h treated surfaces, respectively. The significantly improved tribological properties and biocompatibility have shown the potential of the ceramic conversion treated Zr-BMG for orthopaedic applications.

Evaluation of Titanium Serum Levels in Patients After Spine Instrumentation: Comparison Between Posterolateral and 360º Spinal Fusion Surgery

Introduction

The use of orthopedic implants is a cause for concern for the release of its integrating metals and the systemic complications that may occur. Instrumented spine arthrodesis is the recommended treatment for many spine diseases. Different segmental fixation devices, commonly made of titanium and its alloys, are used in these surgeries. The use of this metal for spinal fusion has introduced the possibility of generating microscopic metal particles that are present in the tissues of the surrounding implants (peri-implant environment). In fact, metal debris has been found in the paraspinal soft tissues of patients with posterior lumbar instrumentation and showed to be particularly high in patients undergoing revision procedures of pseudoarthrosis. In addition, part of the metals might also dissolve (either from the released particles or directly from the implant surface) and circulate in the body fluids, accumulating (eventually) in remote organs.

Material and methods

A prospective study was designed with patients who were to be operated by the pathology of the lumbar spine to perform a vertebral arthrodesis composed of a titanium alloy (n=32). Two subgroups were differentiated according to the type of surgery performed: a) Posterolateral arthrodesis (N=5); b) Circumferential arthrodesis intervertebral implant of polyester-ether ketone (PEEK) (N=8) or titanium (N=19). The blood sample was taken before surgery and one year later. The samples were analyzed by mass spectrophotometry with a double focus inductive coupling plasma source (DF-ICP-MS).

Results

Blood titanium levels prior to surgery were similar to those in other publications (0.7449 micrograms per liter^-1 (µgL^-1), Standard Deviation (SD)=0.562). The average titanium concentration levels found after surgery was 2.5406 µgL^-1 (SD=3,69), near 3.5-fold increase. After surgery, there was a significant mean increase in serum titanium levels of 1.7957 µgL^-1 (SD=3.5765, Range=-0.57 µgL^-1; 14.60 µgL^-1). There is a statistically significant increment (p=0.00049) of the titanium concentration in the serum of the patients after surgery. If we analyze the patients in three groups according to the type of implants used (posterolateral, circumferential with PEEK, and circumferential with titanium), there are no differences between those who did not have an intersomatic device implanted and those in which PEEK implants were implanted, but with those in which it was titanium it was p=0.006 and p=0.018, respectively.

Conclusions

Patients undergoing vertebral instrumentation experience a significant increase in serum titanium levels compared to before surgery levels. The use of an intersomatic device did not show differences in titanium release with not using it when it was PEEK. There are significant differences between patients without intersomatic implants or those who had a PEEK implant with those in whom it was titanium, with a significant increase in blood titanium levels.

Urine Aluminum Concentration as a Possible Implant Biomarker of Pseudomonas aeruginosa Infection Using a Fluorine- and Phosphorus-Doped Ti-6Al-4V Alloy with Osseointegration Capacity

Joint prosthesis failure is mainly related to aseptic loosening and prosthetic joint infections, both associated with high morbidity and a substantial cost burden for patients and health systems. The development of a biomaterial capable of stimulating bone growth while minimizing bacterial adhesion would reduce the incidence of prosthetic failure. Using an in vivo rabbit model, this study evaluates the osseointegration effect of the fluorine (F)- and phosphorus (P)-doped bottle-shaped nanostructured (bNT) Ti-6Al-4V alloy and effectiveness of monitoring urine aluminum concentration to determine the presence of Pseudomonas aeruginosa infection in Ti-6Al-4V implants. Unlike chemically polished (CP) Ti-6Al-4V alloy implants, bNT Ti-6Al-4V alloy implants promoted osseointegration and showed effectiveness as a biomaterial marker. The bNT Ti-6Al-4V alloy implants were associated with a twofold increase in bone thickness and up to 15% greater bone density compared to the CP alloy. Additionally, bNT Ti-6Al-4V alloy implants allowed for discrimination between P. aeruginosa-infected and noninfected animals for 15 days postoperatively, as indicated by the decrease of aluminum concentration in urine, while this difference was only appreciable over the first 7 days when CP Ti-6Al-4V alloy implants were used. Therefore, bNT Ti-6Al-4V alloys could have clinical applications by detecting the infection and by avoiding aseptic loosening.

Does metal porosity affect metal ion release in blood and urine following total hip arthroplasty? A short term study

INTRODUCTION

The surface area of exposed metal in a trabecular-titanium acetabular component is wider compared to traditional-titanium implants. The purpose of this study is to establish if this increase in surface area can lead to a significant increase in systemic metal levels.

METHODS

19 patients with conventional acetabular component and 19 with trabecular-titanium cup were compared. Aluminum, Vanadium and Titanium in blood and urine were assessed before surgery and at intervals for 2 years. The samples were analysed using an inductively coupled plasma mass spectrometry.

RESULTS

Patients with trabecular-titanium did not have significantly higher metal ion levels compared to patients with conventional cups up to 2 years. A trend over time was statistically significant in both blood and urine for aluminum and titanium concentrations.

CONCLUSIONS

The three-dimensionality and the wide surface of the trabecular-titanium acetabular component did not affect metal ion release compared to traditional implants after 2 years.

Evaluation of Blood Titanium Levels and Total Bone Contact Area of Dental Implants

The purpose of this study was to evaluate the effect of total implant-bone surface contact area of dental implants applied on partial or total edentulous patients on the increase in the level of blood titanium level. Changes of the blood titanium levels were evaluated after placement of the dental implants in 30 patients including 15 females and 15 males. Patients were divided into 3 groups as dental implants were applied on only maxilla, only mandible, or both of them. Taking into the consideration anatomic formation and prosthetic indication, dental implant-bone total contact area was calculated and saved for each patient after dental implants placement. Blood samples of the patients taken preoperatively and postoperatively at 12 weeks were analyzed by ICP-MS device. Blood titanium levels of preoperative and postoperative blood samples were analyzed for each patient and results were evaluated statistically. In the evaluation after analyzing blood titanium level changes, while a statistically significant decrease was observed in Group 1 patients, a statistically significant increase was observed in Group 2 and Group 3 patients to blood titanium level. A statistically significant difference was observed between Group 1 and Group 2 and between Group 1 and Group 3 patients of blood titanium levels. The change of the blood titanium level was not related to total implant-bone surface area, number of the implants, and gender. In our study, no correlation was found between change of blood titanium level and total contact area with bone of dental implants. We believe that more accurate results can be obtained with biopsy of tissues and organs on animal studies.

Analysis of soluble or titanium dioxide derived titanium levels in human whole blood: consensus from an inter-laboratory comparison

Exposure to titanium (Ti),viathe ingestion of pigment grade Ti dioxide (TiO₂), is commonplace for westernised populations.

Bonding and bio-properties of hybrid laser/magnetron Cr-enriched DLC layers

Chromium-enriched diamond-like carbon (DLC) layers were prepared by a hybrid technology using a combination of pulsed laser deposition (PLD) and magnetron sputtering. XRD revealed no chromium peaks, indicating that the layers are mostly amorphous. Carbon (sp(2) and sp(3) bonds) and chromium bonds were determined by XPS from C 1s, O 1s, and Cr 2p photoelectron peaks. Depending on the deposition conditions, the concentration of Cr in DLC layers moved from zero to 10 at.% for as-received sample surfaces, and to about 31 at.% after mild sputter-cleaning by argon ion cluster beam. It should be noted that the most stable Cr(3+) bonding state is in Cr2O3 and Cr(OH)3, and that there is the toxic Cr(6+) state in CrO3. The surface content of hexavalent chromium in the Cr 2p3/2 spectra is rather low, but discernible. The population density of Saos-2 cells was the highest in samples containing higher concentrations of chromium 7.7 and 10 at.%. This means that higher concentrations of chromium supported the cell adhesion and proliferation. In addition, as revealed by a LIVE/DEAD viability/cytotoxicity kit, the cells on all Cr-containing samples maintained high viability (96 to 99%) on days 1 and 3 after seeding. However, this seemingly positive cell behavior could be associated with the risk of dedifferentiation and oncogenic transformation of cells.

Metal ions as inflammatory initiators of osteolysis

Osteolysis and aseptic loosening currently contribute 75 % of implant failures. Furthermore, with over four million joint replacements projected to be performed in the United States annually, osteolysis and aseptic loosening may continue to pose a significant morbidity. This paper reviews the osteolysis cascade leading to osteoclast activation and bone resorption at the biochemical level. Additionally, the metal ion release mechanism from metallic implants is elucidated. Even though metal ions are not the predominating initiator of osteolysis, they do increase the concentration of key inflammatory cytokines that stimulate osteoclasts and prove to be a contributor to osteolysis and aseptic loosening. Osteolysis is a competitive mechanism among a number of biological reactions, which includes debris release, macrophage and osteoclast activation, an inflammatory response as well as metal ion release. Pharmacological therapy for component loosening has also been reviewed. A non-surgical treatment of osteolysis has not been found in the literature and thus may become an area of future research. Even though this research is warranted, comprehensively understanding the immune response to orthopedic implants and their metallic ions, and thus, creating improved prostheses appears to be the most cost-effective approach to decrease the morbidity related to osteolysis and to design implants with greater longevity. The ionic forms, cytokines, toxicity, gene expression, biological effects, and hypersensitivity responses of metallic elements from metal implants are summarized as well.

Titania-catalyzed radiofluorination of tosylated precursors in highly aqueous medium

Nucleophilic radiofluorination is an efficient synthetic route to many positron-emission tomography (PET) probes, but removal of water to activate the cyclotron-produced [(18)F]fluoride has to be performed prior to reaction, which significantly increases overall radiolabeling time and causes radioactivity loss. In this report, we demonstrate the possibility of (18)F-radiofluorination in highly aqueous medium. The method utilizes titania nanoparticles, 1:1 (v/v) acetonitrile-thexyl alcohol solvent mixture, and tetra-n-butylammonium bicarbonate as a phase-transfer agent. Efficient radiolabeling is directly performed with aqueous [(18)F]fluoride without the need for a drying/azeotroping step to significantly reduce radiosynthesis time. High radiochemical purity of the target compound is also achieved. The substrate scope of the synthetic strategy is demonstrated with a range of aromatic, aliphatic, and cycloaliphatic tosylated precursors.

Metal ion levels post primary unilateral Exeter total hip arthroplasty

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.

Potential release of in vivo trace metals from metallic medical implants in the human body: from ions to nanoparticles--a systematic analytical review

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.

Possible effects of metallosis on spermatozoal apoptotic genes expression in individuals with intramedullary nailing prosthesis

Seminal quality could be affected by metallosis caused by intramedullary nailing (IMN). Our objectives were to estimate metal ion levels in the seminal plasma of subjects with IMN, to determine their effects on semen parameters and on spermatozoal apoptotic gene expression, and to determine whether these expressed genes could be used as candidate biomarkers of seminal deterioration in individuals with IMN or not. Semen samples were collected from 60 subjects with IMN and 30 age-matched healthy controls. Seminal plasma contents of cobalt (Co), chromium (Cr), and molybdenum (Mo) were assayed. Spermatozoal Bcl-2 and Bax gene expressions were determined. Studied semen parameters were significantly lower in subjects with IMN for ≥5 years in relation to controls while the concentrations of Co, Cr, and Mo in the seminal plasma samples were significantly higher. There were significantly lower spermatozoal Bcl-2 expression, higher Bax expression, and lower Bcl-2/Bax ratio in subjects with IMN for ≥5 years than in controls. In subjects with IMN for ≥5 years, receiver operating characteristic (ROC) curve analysis of studied gene expressions and Bcl-2/Bax ratio were done showing priority of the ratio with 86.7 % sensitivity, 100 % specificity, 100 % positive predictive value, and 93.8 % negative predictive value at cutoff values ≤0.777. Co, Cr, and Mo metals are found at high concentrations in the seminal plasma of individuals with IMN leading to increased spermatozoal apoptotic activity. Spermatozoal Bcl-2/Bax ratio could be used as a candidate biomarker of reproductive disorders in individuals with intramedullary nailing.

Metal ion effects on different types of cell line, metal ion incorporation into L929 and MC3T3-E1 cells, and activation of macrophage-like J774.1 cells

V ions showed high cytotoxicity for mouse fibroblast L929, osteoblastic MC3T3-E1, and macrophage-like J774.1 cells compared with Pb, Cu, Ni, Co, Zn, and Mo ions. The quantities of metal ions incorporated into the L929 and MC3T3-E1 cells increased with increasing metal concentration in the medium, depending on the metal ion type. In particular, the quantities of V incorporated into the cells were markedly higher than those of other metals. It was suggested that the cytotoxicity of a metal ion changes with the quantity of the metal ion incorporated into cells. It was also considered that V ions are incorporated into cells through xanthine derived from fetal bovine serum by high-performance liquid chromatography (HPLC). The strong interaction of Co, Ni and Mo with amino acids was analyzed by HPLC. The rate of increase of nitric oxide (NO) concentration released with the activation of the mouse macrophage-like J774.1 cells increased at a concentration of V ions ten times lower than that of Ni ions. The release of the cytokine tumor necrosis factor-α (TNF-α) from the J774.1 cells started at approximately 0.5 ppm V; interleukin-6 (IL-6) and transforming growth factor-β (TGF-β) showed a marked increase in the rate of increase at more than 1 ppm V. No increase in the concentration of IL-1α, IL-8, IL-15 or granulocyte macrophage-colony stimulating factor (GM-CSF) was observed for V and Ni ions.

Clinical usefulness of blood metal measurements to assess the failure of metal-on-metal hip implants

In April 2010, a Medicines and Healthcare Products Regulatory Agency safety alert concerning all metal-on-metal (MOM) hip replacements recommended measuring chromium and cobalt concentrations when managing patients with painful prostheses. The need for this review is illustrated by the recent surge in requests for these blood tests from orthopaedic surgeons following this alert. The aim is to provide guidance to laboratories in assessing these requests and advising clinicians on interpretation. First, we summarize the basic terminology regarding the types of hip replacements, with emphasis on the MOM type. Second, we describe the clinical concerns over implant-derived wear debris in the local tissues and distant sites. Analytical aspects of the measurement of the relevant metal ions and what factors affect the levels measured are discussed. The application of inductively coupled plasma mass spectrometry techniques to the measurement of these metals is considered in detail. The biological effects of metal wear products are summarized with local toxicity and systemic biological effects considered, including carcinogenicity, genotoxicity and systemic toxicity. Clinical cases are used to illustrate pertinent points.

Metal-on-metal bearings total hip arthroplasty: the cobalt and chromium ions release concern

With certain concerns recently reported on metal-on-metal bearing couples in total hip arthroplasty, this study's objective is to review the current knowledge concerning release of metal ions and its potential consequences. Each metal-on-metal implant presents different tribological properties. The analytical techniques for metals are accurate and the Co ion rates seem acceptable up to 2 μg/L. A delayed type IV hypersensitivity reaction (atypical lymphocytic vasculitis-associated lesion [ALVAL]) may be the source of arthroplasty failure. Idiosyncratic, it remains unpredictable even using cutaneous tests and apparently is rare (0.3%). Today, there are no scientific or epidemiologic data supporting a risk of carcinogenesis or teratogenesis related to the use of a metal-on-metal bearings couple. Solid pseudotumors nearly exclusively are observed with resurfacing procedures, carrying a high annual revision rate in women under 40 years of age, occurring particularly in cases of acetabular malposition and with use of cast molded Cr-Co alloys. Osteolysis manifests through complete and progressive radiolucent lines or through cavitary lesions stemming from ALVAL-type alterations or impingement problems or implant incompatibility. The formation of wear debris exceeding the biological tolerance is possible with implant malposition, subluxation, and jamming of the femoral head in cases of cup deformity. Moreover, each implant presents different metal ion production; assessment of their performance and safety is required before their clinical use. With the knowledge available today, metal-on-metal bearing couples are contraindicated in cases of metal allergies or end stage renal dysfunction and small size resurfacing should cautiously be used.