Evaluation of the method for analyzing chromium, cobalt and titanium ion levels in the blood following hip replacement with a metal-on-metal prosthesis

Multi-elemental determination of metals, metalloids and rare earth element concentrations in whole blood from the Canadian Health Measures Survey, 2009-2011

BACKGROUND

As part of Government of Canada's Chemical Management Plan, substances containing aluminum (Al), bismuth (Bi), cerium (Ce), chromium (Cr), germanium (Ge), lanthanum (La), lithium (Li), neodymium (Nd), praseodymium (Pr), tellurium (Te), titanium (Ti) and yttrium (Y) were identified as priorities for risk assessment. Generating exposure estimates from all routes of exposure from multiple sources using a traditional approach for these elements can be challenging. The use of human biomonitoring (HBM) data would allow for direct and more precise assessment of the internal concentrations from all routes and all sources of exposure. There are no Canadian or North American population-level whole blood HBM data for the elements listed above. Therefore, this is the first biomonitoring project carried out to determine the concentrations of these elements from a nationally representative sample of Canadians.

OBJECTIVES

The objective of this study was to generate whole blood concentrations for Al, Bi, Ce, Cr, Ge, La, Li. Nd, Pr, Te, Ti and Y in the Canadian population using biobank samples from the Canadian Health Measures Survey (CHMS) cycle 2 (2009-2011) for use in characterizing exposure in screening assessments and for establishing baseline concentrations to determine how exposures are changing over time.

METHODS

The sample analysis was conducted by ICP-MS. A rigorous quality control and quality assurance process was implemented in order to generate data with high accuracy and precision while measuring low concentrations and minimizing possible inadvertent contamination.

RESULTS

Of the elements analysed, the whole blood concentrations (μg/L) of Al, Ce, Cr, Ge, La, Nd, Pr, Te, Ti and Y in the Canadian population aged 3-79 years were below their respective method reporting limit (MRL). Two elements, Bi and Li were detected in 5 % and 66 % of the Canadian population. The median Li concentration was 0.47 μg/L.

CONCLUSION

The results of this study provide information on concentrations of these elements in the Canadian population which can be utilized to characterize exposure in screening assessments and there by the potential for harm to human health. In addition, this study provides baseline HBM data which can be used as a comparative HBM dataset for other populations with similar exposure patterns.

Semi-Automated Determination of Heavy Metals in Autopsy Tissue Using Robot-Assisted Sample Preparation and ICP-MS

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.

Importance of Preanalytical Factors in Measuring Cr and Co Levels in Human Whole Blood: Contamination Control, Proper Sample Collection and Long-Term Storage Stability

A number of errors with potentially significant consequences may be introduced at various points in the analytical process, which result in skewed, erroneous analytical results. Precautionary procedures such as contamination control, following established sample collection protocols, and having a complete understanding of the long-term stability of the elements of interest can minimize or eliminate these errors. Contamination control is critical in the quantification of Cr and Co in human whole blood. Cr and Co levels in most biological samples are low, but these elements occur naturally in the environment and are often found in commercial and consumer products, which increases the risk of contamination. In this paper, we demonstrated that lot screening process in which we pre-screen a sub-set of manufactured lots used in collecting, analyzing and storing blood samples is a critical step in controlling Cr and Co contamination. Stainless steel needles are often utilized in blood collection but are considered as a potential source of introducing metal contamination to the patient sample. We conducted two studies to determine if there is a possibility of Cr or Co leaching into the human whole blood from the needles during blood collection. We analyzed blood collected from 100 donors and blood collected in vitro in the laboratory from designated vessel containing spiked blood with higher levels of Cr and Co. Two blood tubes were consecutively collected through one needle. In both studies, Cr and Co concentration levels in the two consecutively collected tubes were compared. Based on the results from donor and in vitro blood collection studies, we concluded that there was no Cr and Co leaching from the limited sets of stainless steel needles used in these studies. Furthermore, we demonstrated that Cr and Co human whole blood samples are stable for 1 year stored at temperatures of -70, -20 and 4°C and 6 months at room temperature.

Using Inductively Coupled Plasma Mass Spectrometry to Assess Essential and Performance-Enhancing Metals in the Urine of Racehorses

Recently, an increased tendency to use various metals has been observed in the sports competition fields. Many of these metals and their organic complexes reportedly have good pharmacologic, therapeutic and performance-enhancement uses; they are banned or recommended as controlled medications in competitive sports. The objective of this research was to determine the concentration of pharmacologically relevant metals in urine samples collected from racehorses at various sport events, develop a method and assess the concentrations of above metals using inductively coupled plasma mass spectrometry (ICP-MS). Seven alkali-alkaline earth metals (lithium, sodium, potassium, magnesium, calcium, strontium and barium) and six heavy metals (chromium, cobalt, copper, zinc, arsenic and selenium) were studied in detail. To compare and confirm the concentrations of these metals, the screening was carried out on the basis of region and sex of the animal. ICP-MS provides extremely high sensitivity that enables the determination of the metals at very low concentration from complex biological matrices. From the research, it is clear that irrespective of sex and region the concentration of metal is very high in some samples, might be accidental or intentional doping to improve sporting performances. This research work is of significant importance in setting threshold values for screening metals in race day samples in order to avoid potential harmful effects on athletes and the depth of malpractices, it can bring to sports.

Whole blood titanium metal ion measurement reproducibility of two laboratories

Background

Metal ion blood concentrations evaluation can be useful in monitoring wear and corrosion of orthopedic implants. Elevated metal ion level may help detecting defective hip arthroplasty implants and serve as an indicator for revision surgery. Our objective was to evaluate the reproducibility of titanium metal ion level measurements by two different laboratories.

Methods

Seventy-one whole blood samples were collected from 64 patients with unilateral ceramic-on-ceramic hip arthroplasty. For each patient, two whole blood samples were collected and analyzed in two different laboratories.

Results

For each case, laboratory 1 had significantly higher values than laboratory 2. There was a clinically significant absolute difference between the two laboratories, above the predetermined threshold, for 90% of samples. A mean variation ratio of 410% between the two laboratories was found.

Conclusion

Not all laboratories use the same techniques and calibrations to perform these measurements. Therefore, their results should be interpreted with caution and clinical decision should rely on metal ion trends provided by the same laboratory.

Increased Serum Ion Levels After Ceramic-on-Metal Bearing Total Hip Arthroplasty: Influence of an Asian Lifestyle

BACKGROUND

Recent clinical studies have suggested that systemic metal ion levels are significantly elevated at midterm follow-up in patients with ceramic-on-metal (COM) bearing. However, it is not clear whether there is a correlation between patient-related factors including the lifestyle and elevated levels of serum metal ions following COM total hip arthroplasty (THA).

METHODS

Serum metal levels were measured in 201 patients (234 hips) including 121 COM patients (140 hips) and 80 non-COM patients (94 hips). The Harris Hip Score, University of California, Los Angeles activity scale score, and Western Ontario and McMaster Universities Osteoarthritis Index score were measured and radiographs were obtained for the analysis.

RESULTS

Significantly higher levels of cobalt (Co) and chromium (Cr) were detected in the serum of the COM THA group (Co: 1.86 ± 4.0 μg/L; Cr: 1.81 ± 2.87 μg/L) than those of the non-COM THA group (Co: 0.27 ± 0.14 μg/L; Cr: 0.19 ± 0.25 μg/L; P < .001). The serum metal levels of patients who achieved the squatting position and the kneeling position were significantly higher than those of patients who could not squat (Co: P = .033; Cr: P = .074) and kneel (Co: P = .049; Cr: P = .031). The metal ion levels of the COM THA group correlated with the total range of motion (Co: P = .0293; Cr: P = .0399).

CONCLUSION

Patients who underwent a 36-mm COM THA showed high serum metal levels although good clinical outcomes at the midterm follow-up. We found that COM THA patients who were capable of greater range of motion, squatting, and kneeling are at risk of metal ion-related problems.

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.

Biomonitoring method for the analysis of chromium and cobalt in human whole blood using inductively coupled plasma - kinetic energy discrimination - mass spectrometry (ICP-KED-MS)

The Centers for Disease Control and Prevention developed a biomonitoring method to rapidly and accurately quantify chromium and cobalt in human whole blood by ICP-MS. Many metal-on-metal hip implants which contain significant amounts of chromium and cobalt are susceptible to metal degradation. This method is used to gather population data about chromium and cobalt exposure of the U.S. population that does not include people that have metal-on-metal hip implants so that reference value can be established for a baseline level in blood. We evaluated parameters such as; helium gas flow rate, choice and composition of the diluent solution for sample preparation, and sample rinse time to determine the optimal conditions for analysis. The limits of detection for chromium and cobalt in blood were determined to be 0.41 and 0.06 μg/L, respectively. Method precision, accuracy, and recovery for this method were determined using quality control material created in-house and historical proficiency testing samples. We conducted experiments to determine if quantitative changes in the method parameters affect the results obtained by changing four parameters while analyzing human whole blood spiked with National Institute of Standard and Technology traceable materials: the dilution factor used during sample preparation, sample rinse time, diluent composition, and kinetic energy discrimination gas flow rate. The results at the increased and decreased levels for each parameter were statistically compared to the results obtained at the optimized parameters. We assessed the degree of reproducibility obtained under a variety of conditions and evaluated the method's robustness by analyzing the same set of proficiency testing samples by different analysts, on different instruments, with different reagents, and on different days. The short-term stability of chromium and cobalt in human blood samples stored at room temperature was monitored over a time period of 64 hours by diluting and analyzing samples at different time intervals. The stability of chromium and cobalt post-dilution was also evaluated over a period of 48 hours and at two storage temperatures (room temperature and refrigerated at 4°C). The results obtained during the stability studies showed that chromium and cobalt are stable in human blood for a period of 64 hours.

High-Performance Polymers and Their Potential Application as Medical and Oral Implant Materials: A Review

PURPOSE

To review the literature on high-performance polymeric (HPP) materials used as medical and oral implants and make comparisons with the commonly used titanium.

MATERIAL AND METHODS

Original scientific articles published in English in MEDLINE (PubMed-NCBI) and Picarta literature databases between January 01, 1995 and June 01, 2013 were included in this review. Additional information was derived from scientific reports, medical and chemical textbooks, handbooks, product information, manufacturers' instructions, and Internet web sites of the manufacturers.

RESULTS

Based on the 7 animal studies and 1 clinical study, HPP polyetheretherketone (PEEK) consisting of a single monomer and featuring a low Young modulus may be advantageous. PEEK seems to lead to less osteolyses and healing problems and no scattering in radiation was observed. Some animal studies showed direct contact between PEEK and the bone with high biocompatibility and no evidence for cytotoxicity, mutagenicity, carcinogenicity, and immunogenicity to the present day.

CONCLUSION

The HPPs (ie, PEEK) may carry some potential to be an alternative material for titanium as medical and dental implants. Yet, clinical and animal studies are limited in the field of implantology with such materials.

Histopathological characterization of corrosion product associated adverse local tissue reaction in hip implants: a study of 285 cases

Background

Adverse local tissue reaction (ALTR), characterized by a heterogeneous cellular inflammatory infiltrate and the presence of corrosion products in the periprosthetic soft tissues, has been recognized as a mechanism of failure in total hip replacement (THA). Different histological subtypes may have unique needs for longitudinal clinical follow-up and complication rates after revision arthroplasty. The purpose of this study was to describe the histological patterns observed in the periprosthetic tissue of failed THA in three different implant classes due to ALTR and their association with clinical features of implant failure.

Methods

Consecutive patients presenting with ALTR from three major hip implant classes (N = 285 cases) were identified from our prospective Osteolysis Tissue Database and Repository. Clinical characteristics including age, sex, BMI, length of implantation, and serum metal ion levels were recorded. Retrieved synovial tissue morphology was graded using light microscopy. Clinical characteristics and features of synovial tissue analysis were compared between the three implant classes. Histological patterns of ALTR identified from our observations and the literature were used to classify each case. The association between implant class and histological patterns was compared.

Results

Our histological analysis demonstrates that ALTR encompasses three main histological patterns: 1) macrophage predominant, 2) mixed lymphocytic and macrophagic with or without features of associated with hypersensitivity/allergy or response to particle toxicity (eosinophils/mast cells and/or lymphocytic germinal centers), and 3) predominant sarcoid-like granulomas. Implant classification was associated with histological pattern of failure, and the macrophagic predominant pattern was more common in implants with metal-on-metal bearing surfaces (MoM HRA and MoM LHTHA groups). Duration of implantation and composition of periprosthetic cellular infiltrates was significantly different amongst the three implant types examined suggesting that histopathological features of ALTR may explain the variability of clinical implant performance in these cases.

Conclusions

ALTR encompasses a diverse range of histological patterns, which are reflective of both the implant configuration independent of manufacturer and clinical features such as duration of implantation. The macrophagic predominant pattern and its mechanism of implant failure represent an important subgroup of ALTR which could become more prominent with increased length of implantation.

Trace metal determination as it relates to metallosis of orthopaedic implants: Evolution and current status

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.

Whole blood metal ion measurement reproducibility between different laboratories

Monitoring patients' metal ion blood concentrations can be useful in cases of problematic metal on metal hip implants. Our objective was to evaluate the reproducibility of metal ion level values measured by two different laboratories. Whole blood samples were collected in 46 patients with metal on metal hip arthroplasty. For each patients, two whole blood samples were collected and analyzed by two laboratories. Laboratory 1 had higher results than laboratory 2. There was a clinically significant absolute difference between the two laboratories, above the predetermined threshold, 35% of Cr samples and 38% of Co samples. All laboratories do not use the same technologies for their measurements. Therefore, decision to revise a metal on metal hip arthroplasty should rely on metal ion trends and have to be done in the same laboratory.

Current role of ICP–MS in clinical toxicology and forensic toxicology: a metallic profile

As metal/metalloid exposure is inevitable owing to its omnipresence, it may exert toxicity in humans. Recent advances in metal/metalloid analysis have been made moving from flame atomic absorption spectrometry and electrothermal atomic absorption spectrometry to the multi-elemental inductively coupled plasma (ICP) techniques as ICP atomic emission spectrometry and ICP–MS. ICP–MS has now emerged as a major technique in inorganic analytical chemistry owing to its flexibility, high sensitivity and good reproducibility. This in depth review explores the ICP–MS metallic profile in human toxicology. It is now routinely used and of great importance, in clinical toxicology and forensic toxicology to explore biological matrices, specifically whole blood, plasma, urine, hair, nail, biopsy samples and tissues.

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.

Clinical features, testing, and management of patients with suspected prosthetic hip-associated cobalt toxicity: a systematic review of cases

Safety concerns regarding cobalt-containing metal alloy hip prosthetics (Co-HP) have resulted in product recalls, a medical device alert, and issuance of guidance for clinicians. Recently, cases of suspected prosthetic hip-associated cobalt toxicity (PHACT) from Co-HP have been reported. Although little is known about suspected PHACT, these patients may be referred to medical toxicologists for evaluation and management recommendations. We searched MEDLINE, EMBASE, and unpublished abstracts from toxicology scientific meetings for references relevant to PHACT. Authors independently screened publications for inclusion criteria: publication in English, human study population, subject(s) are symptomatic (except for isolated hip pain), and cobalt values in any matrix (blood, serum, urine, CSF, synovial fluid) available for review. Data from 10 cases are reviewed. Patients with suspected PHACT had findings consistent with cobalt toxicity, including thyroid, cardiac, and neurologic dysfunction. Signs and symptoms appeared between 3 and 72 months after arthroplasty (median 19 months). Neurologic symptoms were most common. Ancillary testing varied considerably. All patients had elevated cobalt levels in one or more matrices. Enhanced elimination was attempted in 27 % of patients. At this time, the information currently available regarding patients with suspected PHACT is inadequate to guide clinical decision making. No consensus has been reached regarding the management of Co-HP patients with systemic symptoms. Indications for chelation have not been established and require further study. Improved case definitions, improved surveillance, and controlled studies are needed to elucidate the scope of this problem and guide future investigations.

Detection of cobalt in synovial fluid from metal-on-metal hip prosthesis: correlation with the ion haematic level

Hip replacement with large metal-on-metal (MoM) coupling has recently been under attention for its metal ions release, inducing several disorders. Since the blood level toxicity threshold for cobalt is known, the aim of this work is to determine whether Co serum and blood levels correlate with the synovial fluid level. Beside this, the synovial fluid Co from patients without prosthesis has also been measured. Co has been determined in 54 samples (32 unilateral MoM and 22 controls) with inductively coupled plasma mass spectrometry in the three matrices. In the prosthesized group, cobalt was significantly higher compared with controls and in the synovial fluid it strongly correlated with whole blood Co (p = 0.847) and serum (p = 0.855). Moreover, the Co levels into whole blood and serum were significantly different. In conclusion, haematic Co concentration correctly reflects Co local level.

Vanadium release in whole blood, serum and urine of patients implanted with a titanium alloy hip prosthesis

INTRODUCTION

Vanadium (V) is a minor constituent of the Titanium-Aluminum-Vanadium (TiAlV) alloy currently used in cementless hip prostheses. Present study aimed at verifying the correlation of vanadium levels among different matrices and assessing reference levels of the ion in a population of patients wearing a well-functioning hip prosthesis.

METHODS

Vanadium was measured using Inductive Coupled Plasma Mass Spectrometry (ICP-MS) in whole blood, serum and urine of 129 patients implanted with a TiAlV-alloy hip prosthesis.

RESULTS

The values in the serum were above the upper limit of the reference values in 42% of patients (29% in urine and 13% in whole blood). A good correlation among matrices was observed (p < 0.001). The cohort of patients (N = 32) complaining of pain or in which a loosening or damage to the prosthesis was assessed showed a significantly higher excretion of vanadium in urine as compared with the remaining asymptomatic patients (p = 0.001). The 95th percentile distribution of vanadium in the cohort of patients with a well-functioning prosthesis was 0.3 μg/L in whole blood, 0.5 μg/L in serum and 2.8 μg/L in urine, higher that in the unexposed population, especially for urine.

CONCLUSIONS

The presence of a prosthesis, even though well-functioning, may cause a possible release of vanadium into the blood and a significant urinary excretion. The reference values of vanadium of the asymptomatic patients with titanium alloy hip prostheses supplied information regarding the background exposure level of the ions and their lower and upper limits.