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Burgos J, Hevia E, Sanpera I, García V, de Santos Moreno MT, Mariscal G, Barrios C. Elevated blood metal ion levels in patients undergoing instrumented spinal surgery: a systematic review and meta-analysis. Spine J 2024; 24:947-960. [PMID: 38437920 DOI: 10.1016/j.spinee.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/24/2024] [Accepted: 02/25/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND CONTEXT Elevated blood metal levels have been reported in patients after spinal surgery using metallic implants. Although some studies have suggested an association between heightened blood metal concentrations and potential adverse effects, estimates of the incidence of abnormal metal levels after spinal surgery have been inconsistent. PURPOSE The aims of this systematic review and meta-analysis were to assess: (1) mean differences in blood metal ion levels between patients undergoing spinal fusion surgery and healthy controls, (2) odds of elevated blood metal ion levels after surgery compared to presurgery levels, and (3) pooled incidence of elevated blood metal ions overall and by metal type. STUDY DESIGN Systematic review and meta-analysis. PATIENTS SAMPLE The patient sample included 613 patients from 11 studies who underwent spinal surgery instrumentation. OUTCOME MEASURES Blood metal ion concentrations and the incidence of patients with elevated metal levels compared with in those the control group. METHODS A comprehensive search was conducted in PubMed, EMBASE, Scopus, and Cochrane Library to identify studies reporting blood metal ion levels after spinal fusion surgery. Mean differences (MD), odds ratios (OR), and incidence rates were pooled using random effects models. Heterogeneity was assessed using I2 statistics, and fixed-effects models were used if no heterogeneity was detected. Detailed statistical analysis was performed using the Review Manager version 5.4 software. RESULTS The analysis included 11 studies, with a total of 613 patients. Mean blood metal ion levels were significantly higher after spinal fusion surgery (MD 0.56, 95% CI 0.17-0.96; I2=86%). Specifically, titanium levels were significantly elevated (MD 0.81, 95% CI 0.32-1.30; I2=47%). The odds of elevated blood metal ions were higher after surgery (OR 8.17, 95% CI 3.38-19.72; I2=41%), primarily driven by chromium (OR 23.50, 95% CI 5.56-99.31; I2=30%). The incidence of elevated chromium levels was found to be 66.98% (95% CI 42.31-91.65). CONCLUSION In conclusion, blood metal ion levels, particularly titanium and chromium, were significantly increased after spinal fusion surgery compared to presurgery levels and healthy controls. Approximately 70% of the patients exhibited elevated blood levels of chromium and titanium.
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Affiliation(s)
- Jesús Burgos
- Vithas Internacional, C/ de Arturo Soria, 107, Cdad. Lineal, 28043 Madrid, Spain
| | - Eduardo Hevia
- Spine Unit, University of Navarra Clinic, C. del Marquesado de Sta. Marta, 1, San Blas-Canillejas, 28027, Madrid, Spain
| | - Ignacio Sanpera
- Pediatric Orthopedics, Son Espases Hospital, Spain de Valldemossa, 79, Nord, 07120 Palma, Illes Balears, Spain
| | - Vicente García
- Spine Surgery Section, Araba University Hospital, Jose Atxotegi Kalea, s/n, Txagorritxu, 01009 Gasteiz, Araba, Spain
| | - María Teresa de Santos Moreno
- Neuropediatrics Unit, San Carlos Clinic Hospital, Calle del Prof Martín Lagos, S/N, Moncloa - Aravaca, 28040 Madrid, Spain
| | - Gonzalo Mariscal
- Mediterranean Observatory for Clinical and Health Research (OMEDICS), Carrer Quevedo 1, 46001, Valencia, Spain; Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, C/ de Quevedo, 2, Ciutat Vella, 46001 Valencia, Spain.
| | - Carlos Barrios
- Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, C/ de Quevedo, 2, Ciutat Vella, 46001 Valencia, Spain
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Shams K, Jha S, Swallow J, Caird MS, Farley FA, Stepanovich M, Li Y. Serum Titanium Levels Remain Elevated But Urine Titanium is Undetectable in Children With Early Onset Scoliosis Undergoing Growth-Friendly Surgical Treatment: A Prospective Study. J Pediatr Orthop 2024; 44:37-42. [PMID: 37953656 DOI: 10.1097/bpo.0000000000002565] [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] [Indexed: 11/14/2023]
Abstract
BACKGROUND Elevated serum titanium levels have been found in patients with early onset scoliosis (EOS) treated with traditional growing rods (TGR), magnetically controlled growing rods (MCGR), and vertical expandable prosthetic titanium rib (VEPTR). No studies have investigated whether serum titanium remains persistently elevated and if titanium is excreted. Our purpose was to compare serum titanium levels in patients with EOS with growth-friendly instrumentation to age-matched controls and evaluate urine titanium and serial serum titanium levels in patients with EOS. METHODS This was a prospective case-control study. Patients with EOS with TGR, MCGR, or VEPTR underwent urine titanium and serial serum titanium collection at a minimum 6-month interval. Control patients did not have a history of metal implant insertion and underwent serum titanium collection before fracture fixation. RESULTS Twenty patients with EOS (6 TGR, 8 MCGR, and 6 VEPTR) and 12 controls were analyzed. The control group had no detectable serum titanium (0 ng/mL), whereas the patients with EOS had a median serum titanium of 4.0 ng/mL ( P < 0.001). Analysis of variance showed significantly higher median serum titanium levels in the MCGR and VEPTR groups than the TGR group at time point 1 (5.5 vs 6.0 vs 2.0 ng/mL, P = 0.01) and time point 2 (6.5 vs 7.5 vs 2.0 ng/mL, P < 0.001). Binary comparisons showed a significant difference in serum titanium level between TGR and MCGR (time point 1: P = 0.026, time point 2: P = 0.011) and TGR and VEPTR (time point 1: P = 0.035, time point 2: P = 0.003). However, there was no difference between MCGR and VEPTR (time point 1: P = 0.399, time point 2: P = 0.492) even though the VEPTR group had a longer duration of follow-up ( P = 0.001) and a greater number of lengthenings per patient at the first serum collection ( P = 0.016). No patients with EOS had detectable urine titanium. CONCLUSIONS Patients with EOS treated with titanium alloy growth-friendly instrumentation had elevated serum titanium levels compared with age-matched controls that persisted over time with no evidence of renal excretion. Additional studies are necessary to assess for local and systemic accumulation of titanium and the significance of long-term exposure to titanium in growing children. LEVEL OF EVIDENCE Level III, therapeutic.
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Affiliation(s)
- Kameron Shams
- Department of Orthopaedic Surgery, University of Michigan
| | - Sahil Jha
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI
| | - Jennylee Swallow
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI
| | - Michelle S Caird
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI
| | | | - Matthew Stepanovich
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI
| | - Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI
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Cundy PJ, Antoniou G, Freeman BJC, Cundy WJ. Persistently Raised Serum Titanium Levels After Spinal Instrumentation in Children. Spine (Phila Pa 1976) 2022; 47:1241-1247. [PMID: 35960139 DOI: 10.1097/brs.0000000000004406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/23/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective study of patients undergoing elective spinal deformity surgery with repeated testing for circulating metal ions including preoperative levels acting as controls. OBJECTIVE The aim was to determine if levels of particular circulating metal ions are maintained to two years postsurgery including different implant systems and rods. SUMMARY OF BACKGROUND DATA Adults having hip replacements, especially metal-on-metal bearings, may develop high metal ion levels. Pediatric spinal implants are known to cause circulating metal ions, notably titanium, chromium, cobalt, and nickel. MATERIALS AND METHODS Fifty-six children having spinal deformity surgery were studied with repeated testing for circulating metal ions, using high-resolution inductively coupled plasma mass spectrometry. Linear mixed-effects models adjusting for repeated measurements over time were used to analyze levels of titanium, cobalt, chromium, and nickel. RESULTS Titanium levels showed a rapid increase by seven days and a peak at 30 days that was essentially maintained at the two-year assay. At two years, titanium levels were 5.14 times greater compared with the presurgery control level (P<0.0001). Cobalt levels were shown to gradually rise to a peak at 30 days and then slowly decline but remained 1.74 times above mean baseline level at two years (P=0.0004), with a declining trajectory. Chromium and nickel levels rose immediately postoperatively and then steadily declined to baseline by six months and remained at baseline at two years. The five implant systems tested had generally equivalent results. CONCLUSION The persistent and rising levels of titanium, in a predominantly female population, is concerning. Titanium is known to cross the placental barrier and enter the circulation of the fetus in rodents and humans, and to accumulate in solid organs especially the liver, spleen, heart, and lymph nodes in humans. This potentially exposes the offspring of mothers with spinal implants to titanium, with potential teratogenic effects.
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Affiliation(s)
- Peter J Cundy
- Department of Orthopaedic Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
- Centre for Orthopaedic and Trauma Research, University of Adelaide, SA, Australia
| | - Georgia Antoniou
- Department of Orthopaedic Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
| | - Brian J C Freeman
- Department of Orthopaedic Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
- Centre for Orthopaedic and Trauma Research, University of Adelaide, SA, Australia
| | - William J Cundy
- Department of Orthopaedic Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
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Danielewicz A, Wójciak M, Sawicki J, Dresler S, Sowa I, Latalski M. Comparison of Different Surgical Systems for Treatment of Early-onset Scoliosis in the Context of Release of Titanium Ions. Spine (Phila Pa 1976) 2021; 46:E594-E601. [PMID: 33290378 PMCID: PMC8614546 DOI: 10.1097/brs.0000000000003846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/04/2020] [Accepted: 10/08/2020] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case-control study. OBJECTIVE The aim of the study was to compare growth-friendly systems: traditional growing rod, guided growth systems (GGS), and vertical expandable prosthetic titanium rib in the context of titanium release. SUMMARY OF BACKGROUND DATA The problem of scoliosis affects even up to 3% of the population, and ca. 0.1% of patients need surgical treatment. Surgical treatment carries the risk of a long-term presence of implants in the organism, which may result in release of metal ions into the tissues and bloodstream. METHODS Seventy-one patients (13.5 ± 3.54 years' old) were treated for spinal deformity using various surgical systems and the samples of paraspinal tissue, blood, nails, and hair were collected before and after treatment. The quantification of titanium was performed using inductively coupled plasma optical emission spectrometry. RESULTS The metallic particles were released into the peri-implant tissue, and the greatest amounts of titanium were detected in patients with GGS. The concentration of soluble titanium forms in subcutaneous tissue (ST) was low and do not statistically differ from control. The average titanium content in the paraspinal tissue in patients with GGS was two- to three-fold higher than the average value in the other investigated groups. A slightly increased level of titanium compared with the control was noted in all studied groups of patients. The highest content of titanium in blood was observed in patients with the GGS system. CONCLUSION Neverless the system used, the concentration of soluble titanium forms in both ST and blood was only slightly higher than in the control and did not exceed the allowable levels. The increased level of titanium with GGS system is probably associated with the friction between implant components, whereas the components in the other systems are immobile relative to each other.Level of Evidence: 3.
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Affiliation(s)
- Anna Danielewicz
- Department of Paediatric Orthopaedics, Medical University of Lublin, Lublin, Poland
| | - Magdalena Wójciak
- Department of Analytical Chemistry, Medical University of Lublin, Lublin, Poland
| | - Jan Sawicki
- Department of Analytical Chemistry, Medical University of Lublin, Lublin, Poland
| | - Sławomir Dresler
- Department of Analytical Chemistry, Medical University of Lublin, Lublin, Poland
| | - Ireneusz Sowa
- Department of Analytical Chemistry, Medical University of Lublin, Lublin, Poland
| | - Michał Latalski
- Department of Paediatric Orthopaedics, Medical University of Lublin, Lublin, Poland
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Ulusaloğlu AC, Atici T, Ermutlu C, Akesen S. Evaluation of titanium release from titanium alloy implants in patients with spinal instrumentation. J Int Med Res 2021; 49:300060520984931. [PMID: 33472477 PMCID: PMC7829528 DOI: 10.1177/0300060520984931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective This study was performed to investigate the baseline serum titanium levels in
patients with short-segment titanium alloy posterior instrumentation and to
assess patient-, implant-, and surgery-related factors that might affect the
serum titanium level. Method Two groups of patients were included in the study. The study group comprised
39 patients who had undergone short-segment posterior instrumentation from
January 2013 to June 2016. The control group comprised 11 randomly selected
patients who presented to the outpatient clinic with no history of
orthopedic surgery. The serum titanium levels and inter-group differences
were analyzed. Results The mean serum titanium level was significantly higher in the study group
than in the control group. No significant difference was observed between
patients with different etiologies, implants used for fusion, numbers of
instrumented segments, or postoperative durations. Conclusion The serum titanium levels of patients with posterior lumbar spinal
instrumentation are significantly higher than those of the normal population
even after achievement of solid fusion. These levels are not affected by the
use of transverse connectors, the use of cages, the operated segments, or
the duration of implants.
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Affiliation(s)
- Armağan Can Ulusaloğlu
- Health Sciences University, Bursa Yüksek İhtisas Training and Research Hospital, Orthopaedics and Traumatology Clinic, Bursa, Turkey
| | - Teoman Atici
- Uludag University Faculty of Medicine, Department of Orthopaedics and Traumatology, Bursa, Turkey
| | - Cenk Ermutlu
- Uludag University Faculty of Medicine, Department of Orthopaedics and Traumatology, Bursa, Turkey
| | - Selcan Akesen
- Uludag University Faculty of Medicine Department of Anesthesiology and Intensive Care, Bursa, Turkey
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Tognini M, Hothi H, Dal Gal E, Shafafy M, Nnadi C, Tucker S, Henckel J, Hart A. Understanding the implant performance of magnetically controlled growing spine rods: a review article. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:1799-1812. [PMID: 33666742 DOI: 10.1007/s00586-021-06774-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/14/2021] [Accepted: 02/13/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Early-Onset Scoliosis (EOS) (defined as a curvature of the spine ≥ 10° with onset before 10 years of age) if not properly treated, can lead to increased morbidity and mortality. Traditionally Growing Rods (TGRs), implants fixated to the spine and extended every 6-8 months by surgery, are considered the gold standard, but Magnetically Controlled Growing Rods (MCGRs) avoid multiple surgeries. While the potential benefit of outpatient distraction procedure with MCGR is huge, concerns still remain about its risks, up to the release of a Medical Device Alert (MDA) by the Medicines and Healthcare Regulatory Agency (MHRA) advising not to implant MCGRs until further notice. The aim of this literature review is to (1) give an overview on the use of MCGRs and (2) identify what is currently understood about the surgical, implant and patient factors associated with the use of MCGRs. METHODS Systematic literature review. RESULTS Surgical factors such as use of single rod configuration or incorrect rod contouring might affect early failure of MCGRs. Patient's older age and higher BMI are correlated with rod slippage. Wear debris and distraction mechanism failure may result from implant design and iteration. CONCLUSION Despite the complications reported, this technology still offers one of the best solutions to spine surgeons dealing with severe EOS. Lowering the complication rate by identifying risk factors for failure is possible and further studies in this direction are required. Once the risk factors are well described, some of these can be addressed enabling a safer use of MCGRs.
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Affiliation(s)
- Martina Tognini
- The Royal National Orthopaedic Hospital and Institute of Orthopaedics and Musculoskeletal Science, University College London, Stanmore, UK.
| | - Harry Hothi
- The Royal National Orthopaedic Hospital and Institute of Orthopaedics and Musculoskeletal Science, University College London, Stanmore, UK
| | - Elisabetta Dal Gal
- The Royal National Orthopaedic Hospital and Institute of Orthopaedics and Musculoskeletal Science, University College London, Stanmore, UK
| | - Masood Shafafy
- Department of Trauma and Orthopaedics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Colin Nnadi
- Nuffield Orthopaedic Centre, Oxford University Hospital, Headington, Oxford, UK
| | - Stewart Tucker
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Johann Henckel
- The Royal National Orthopaedic Hospital and Institute of Orthopaedics and Musculoskeletal Science, University College London, Stanmore, UK
| | - Alister Hart
- The Royal National Orthopaedic Hospital and Institute of Orthopaedics and Musculoskeletal Science, University College London, Stanmore, UK
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Analysis of serum levels of titanium and aluminium ions in patients with early onset scoliosis operated upon using the magnetic growing rod-a single centre study of 14 patients. Spine Deform 2021; 9:1473-1478. [PMID: 34297320 PMCID: PMC8363538 DOI: 10.1007/s43390-021-00335-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/15/2021] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN A cross-sectional retrospective Level 3 study. OBJECTIVE To study the serum levels of Titanium and Aluminium ions in patients operated using the magnetically controlled growing rod (MCGR) system. 14 consecutive patients of early onset scoliosis with varying etiology managed with MCGR system with a minimum follow-up of 24 months were selected for the study. The group consisted of two boys (14.3%) and 12 girls (85.7%). The average age of the patients at the time of surgery was 10.4 years (5-15 years). The average period of follow-up was 43.7 months (28-79 months). After informed consent of the subjects and their caretakers, serum levels of titanium and aluminium were measured. These levels were then assessed with regards to the number of screws used, number of distractions and complications. METHODS The concentration of titanium and aluminium ions in the serum was measured using high resolution inductively coupled plasma mass spectrometry. RESULTS For the sake of ease of assessment, patients were divided into three etiology-based groups-idiopathic (n = 6), neuromuscular (n = 2) and syndromic (n = 6). The mean serum titanium level was 15.9 μg/L (5.1-28.2 μg/L) while that of aluminium was 0.1 μmol/L (0.1-0.2 μmol/L). Of the 14 patients, 2 (14.2%) patients had mechanical failure (actuator pin dysfunction), 3 (21.4%) had rod breakage requiring revision surgery and one patient (7.1%) had surgical site infection managed with appropriate antibiotics. Patients undergoing revision for rod breakage did not show any metallosis of the tissues during surgery. CONCLUSION Analysis of patients with scoliosis operated using the magnetic growing rod system concludes that it is accompanied by presence of titanium in the blood but whether clinically significant or not needs to be ascertained by comparison of preoperative and postoperative blood concentrations of the titanium ions in individual subjects. The aluminium ion concentration remains within normal limits. Though implant malfunction may raise the titanium levels in the blood, its clinical significance needs to be determined. The aluminium levels are not affected irrespective to the presence or absence of complications. The long-term effects of raised titanium levels in the blood also warrant further prospective studies designed for precise and deeper analyses.
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Siddiqi O, Urquhart JC, Rasoulinejad P. A systematic review of metal ion concentrations following instrumented spinal fusion. Spine Deform 2021; 9:13-40. [PMID: 32780305 DOI: 10.1007/s43390-020-00177-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/27/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Metallic spinal implants undergo wear and corrosion which liberates ionic or particulate metal debris. The purpose of this study was to identify and review studies that report the concentration of metal ions following multi-level spinal fusion and to evaluate the impact on clinical outcomes. METHODS Databases (PubMed, EBSCO MEDLINE) were searched up to August 2019 for studies in English-language assessing metal ion levels [chromium (Cr), titanium (Ti), nickel (Ni)] in whole blood, serum, or plasma after spinal fusion using a specific search string. Study, patient, and implant characteristics, method of analysis, metal ion concentration, as well as clinical and radiographic results was extracted. RESULTS The systematic search yielded 18 studies encompassing 653 patients. 9 studies reported Ti ions, eight reported Cr, and six reported Ni. Ti levels were elevated compared to controls/reference range/preoperative baseline in seven studies with the other two reporting no difference. Cr levels were elevated compared to controls/reference range in seven studies with one reporting no difference. Ni levels showed no difference from controls/reference range in four studies with one reporting above normal and another elevated compared to controls. Radiographic evidence of corrosion, implant failure, pseudarthrosis, revision surgery and adverse reaction reporting was highly variable. CONCLUSION Metal ions are elevated after instrumented spinal fusion; notably Cr levels from stainless steel implants and Ti from titanium implants. The association between clinical and radiographic outcomes remain uncertain but is concerning. Further research with standardized reporting over longer follow-up periods is indicated to evaluate the clinical impact and minimizing risk.
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Affiliation(s)
| | - Jennifer C Urquhart
- Department of Surgery, London Health Sciences Center, E1-311, 800 Commissioners Road, East, London, ON, N6A 4G5, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Parham Rasoulinejad
- Department of Surgery, London Health Sciences Center, E1-311, 800 Commissioners Road, East, London, ON, N6A 4G5, Canada. .,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. .,Lawson Health Research Institute, London, ON, Canada.
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Chromium Metal Ion Release During Instrumented Spinal Surgery in Children: The Effects of Electrosurgery. Spine (Phila Pa 1976) 2020; 45:1619-1624. [PMID: 32890308 DOI: 10.1097/brs.0000000000003661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective 2-year study with operative sampling and in-vitro analysis of chromium ions following spinal surgery in children. OBJECTIVES To measure metal ion levels at preoperative, intraoperative, and postoperative times to determine patterns of metal ion release during instrumented spinal surgery. SUMMARY OF BACKGROUND DATA Raised serum metal ion levels are reported following instrumented spinal fusion in adolescent idiopathic scoliosis. The authors noted raised chromium levels in patients receiving implants that did not contain chromium. This prompted further work to establish the source. The electrosurgery tips used were discovered to contain 17% chromium. METHODS Chromium, cobalt, and titanium levels were measured before, during, and after surgery in serum and local intraoperative fluid samples in 11 children undergoing posterior instrumentation for scoliosis. Administered drugs, cell-saver fluids, and intraoperative fluids, both local and intravenous, were investigated to exclude these as sources of chromium ions. An in-vitro study was also performed to elucidate sources of intraoperative chromium ions. RESULTS High chromium levels were detected in all samples from the wound irrigation fluid prior to insertion of metal implants. Immediate postoperative chromium serum ion levels were also elevated and returned to baseline by day 30. In-vitro sampling of fluids from test models using electrosurgery revealed high levels of chromium ions CONCLUSION.: This finding of high chromium metal ion concentrations in intraoperative and early postoperative samples provides evidence of chromium release during the dissection phase of spinal surgery. This challenges existing beliefs that metal ion release occurs solely due to implants and now implicates the electrosurgery electrode tips as a source of raised chromium ion levels. Thorough irrigation of the operative site after the dissection phase of surgery to both dilute and reduce the intraoperative chromium ion load is suggested. Alternative electrosurgery electrode tips or other methods to coagulate during surgery could be considered. LEVEL OF EVIDENCE 2.
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Do Children With Spinal Deformity Who Have Metal Implants and Frequent Exposure to X-Rays Increase Their Risk of Cancer? Spine (Phila Pa 1976) 2020; 45:1200-1207. [PMID: 32355145 DOI: 10.1097/brs.0000000000003507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Spinal surgery cohort. OBJECTIVE The authors assess the risk of cancer in children who have undergone frequent radiographs and have metal implants for the treatment of spinal deformity. SUMMARY OF BACKGROUND DATA Concerns have been raised regarding the cancer risk to children exposed to repeated radiological examinations as part of routine surveillance to monitor progression of spinal deformity. Additionally, there are reports of increased cancer risk in adults having joint replacement with metal implants causing raised metal ion levels in the blood. METHODS A large number of consecutive children undergoing instrumented spinal surgery since 1979 were examined for their development of malignancy. High quality data on all invasive cancers from the South Australian Cancer Registry and deaths were linked to the spinal surgery cohort with the calculation of standardized incidence ratios (SIRs) using the Quinquinquennium method. RESULTS The study cohort was formed by 865 children. The average follow-up time from date of surgery to either death or censoring date was 18 years with a maximum of 36 years. A total of 15,921 person years were examined. There was no increased rate of cancer in these patients. For the total cohort, the SIR was 1.00 (95% confidence interval [CI] 0.50-1.79). For females the SIR was 0.83 (95% CI 0.33-1.70) and for males the SIR was 1.33 (95% CI 0.36-3.40). The male SIR reflected an expected cancer incidence of three cases, when four cases were observed, and was not statistically significant. CONCLUSION This study has found that radiation exposure and possible exposure to circulating metal ions as a result of routine instrumented spine surgery in children since 1979 is not associated with an increased risk of cancer in up to 36 years of follow up. LEVEL OF EVIDENCE 2.
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Yao JJ, Lewallen EA, Thaler R, Dudakovic A, Wermers M, Day P, Eckdahl S, Jannetto P, Bornhorst JA, Larson AN, Abdel MP, Lewallen DG, van Wijnen AJ. Challenges in the Measurement and Interpretation of Serum Titanium Concentrations. Biol Trace Elem Res 2020; 196:20-26. [PMID: 31696354 DOI: 10.1007/s12011-019-01891-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/03/2019] [Indexed: 11/25/2022]
Abstract
The measurement of circulating metal ion levels in total hip arthroplasty patients continues to be an area of clinical interest. National regulatory agencies have recommended measurement of circulating cobalt and chromium concentrations in metal-on-metal bearing symptomatic total hip arthroplasty patients. However, the clinical utility of serum titanium (Ti) measurements is less understood due to wide variations in reported values and methodology. Fine-scale instrumentation for detecting in situ Ti levels continues to improve and has transitioned from graphite furnace atomic absorption spectroscopy to inductively coupled plasma optical emission spectrometry or inductively coupled plasma mass spectrometry. Additionally, analytical interferences, variable sample types, and non-standardized sample collection methods complicate Ti measurement and underlie the wide variation in reported levels. Normal reference ranges and pathologic ranges for Ti levels remain to be established quantitatively. However, before these ranges can be recognized and implemented, methodological standardization is necessary. This paper aims to provide background and recommendations regarding the complexities of measurement and interpretation of circulating Ti levels in total hip arthroplasty patients.
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Affiliation(s)
- Jie J Yao
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Eric A Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
- Department of Biological Sciences, Hampton University, Hampton, VA, USA
| | - Roman Thaler
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
| | - Amel Dudakovic
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Michelle Wermers
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Patrick Day
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Steve Eckdahl
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Paul Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Joshua A Bornhorst
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
| | - David G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA
| | - Andre J van Wijnen
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA.
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA.
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12
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Tanoğlu O, Say F, Yücens M, Alemdaroğlu KB, İltar S, Aydoğan NH. Titanium Alloy Intramedullary Nails and Plates Affect Serum Metal Ion Levels within the Fracture Healing Period. Biol Trace Elem Res 2020; 196:60-65. [PMID: 31621008 DOI: 10.1007/s12011-019-01913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/20/2019] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Oğuzhan Tanoğlu
- Faculty of Medicine, Department of Orthopedics and Traumatology, Erzincan Binali Yıldırım University, Erzincan, Turkey.
| | - Ferhat Say
- Faculty of Medicine, Department of Orthopedics and Traumatology, Ondokuz Mayıs University, Samsun, Turkey
| | - Mehmet Yücens
- Faculty of Medicine, Department of Orthopedics and Traumatology, Pamukkale University, Denizli, Turkey
| | - Kadir Bahadır Alemdaroğlu
- Department of Orthopedics and Traumatology, SBU Ankara Research and Training Hospital, Ankara, Turkey
| | - Serkan İltar
- Department of Orthopedics and Traumatology, SBU Ankara Research and Training Hospital, Ankara, Turkey
| | - Nevres Hürriyet Aydoğan
- Faculty of Medicine, Department of Orthopedics and Traumatology, Muğla Sıtkı Koçman University, Muğla, Turkey
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Elevated Serum Titanium Levels in Children With Early Onset Scoliosis Treated With Growth-friendly Instrumentation. J Pediatr Orthop 2020; 40:e420-e423. [PMID: 32501902 DOI: 10.1097/bpo.0000000000001463] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A previous study showed significantly higher serum titanium levels in patients with early-onset scoliosis (EOS) treated with traditional growing rods (TGR) and magnetically controlled growing rods (MCGR) compared with controls. Children with vertical expandable prosthetic titanium rib (VEPTR) were not assessed. The purpose of this study was to compare serum titanium levels in EOS patients treated with TGR, MCGR, and VEPTR. We hypothesized that EOS patients treated with all forms of growth-friendly instrumentation (GFI) have elevated serum titanium levels. METHODS This was a prospective cross-sectional case series. Serum titanium levels were collected from patients with GFI who were enrolled in an EOS database. Blood samples were collected at a clinic visit or lengthening/exchange procedure between April and December 2018. The normal range for serum titanium is 0 to 1 ng/mL. Analyses were conducted using analysis of variance and Bonferroni post hoc test. RESULTS A total of 23 patients (2 TGR, 8 MCGR, 13 VEPTR) were analyzed. There was a significant difference in age at the time of blood sample collection (12.5 vs. 9.8 vs. 7.5 y, P=0.015) and serum titanium level (1.5 vs. 4.5 vs. 7.6 ng/mL, P=0.021) between TGR, MCGR, and VEPTR, respectively. All of the MCGR and VEPTR patients had a serum titanium level ≥2 ng/mL. Binary comparisons showed that VEPTR had a significantly higher serum titanium level than TGR (P=0.046). There was no difference in serum titanium level when MCGR was compared with TGR and VEPTR. Time from implant insertion to blood sample collection, number of rods currently implanted, total number of rods implanted throughout treatment, and number of lengthenings per patient was similar between the groups. CONCLUSIONS Elevated serum titanium levels may be present in EOS patients treated with all forms of GFI. Although our TGR patients had indwelling implants for the longest period of time, they had the lowest serum titanium level. Repetitive chest wall motion during respiration may lead to continued wear and metal ion release with VEPTR. LEVEL OF EVIDENCE Level II-therapeutic.
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14
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Fernández Bances I, Paz Aparicio J, Alvarez Vega MA. Evaluation of Titanium Serum Levels in Patients After Spine Instrumentation: Comparison Between Posterolateral and 360º Spinal Fusion Surgery. Cureus 2019; 11:e5451. [PMID: 31511816 PMCID: PMC6716769 DOI: 10.7759/cureus.5451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
| | - José Paz Aparicio
- Spine Unit, Orthopedic Surgery and Traumatology Department, University Central Hospital of Asturias, Oviedo, ESP
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15
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Henríquez-Hernández LA, González-Antuña A, Boada LD, Carranza C, Pérez-Arellano JL, Almeida-González M, Camacho M, Zumbado M, Fernández-Fuertes F, Tapia-Martín M, Luzardo OP. Pattern of blood concentrations of 47 elements in two populations from the same geographical area but with different geological origin and lifestyles: Canary Islands (Spain) vs. Morocco. THE SCIENCE OF THE TOTAL ENVIRONMENT 2018; 636:709-716. [PMID: 29727838 DOI: 10.1016/j.scitotenv.2018.04.311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/23/2018] [Accepted: 04/23/2018] [Indexed: 05/12/2023]
Abstract
The Canary Islands are one of the outermost regions of the European Union (EU), which are located barely 100 km from the coasts of Morocco. Although these islands are located in Africa, the degree of socioeconomic development and lifestyle in this archipelago is comparable to that of any other region of Europe. It is well established that the main determinants of human exposure to elements have to do both, with their place of residence and with habits related to their lifestyle. For this reason, we wanted to study the pattern of contamination by elements of these two populations so geographically close, but so different both in their lifestyle, and the geological origin of the territory where they live. Thus, we have determined the blood concentrations of 47 elements (including 25 rare earth elements (REE) and other minority elements (ME) widely employed in the hi-tech industry) in a paired sample of Moroccans (n = 124) and Canary Islands inhabitants (n = 120). We found that the levels of iron, selenium, zinc, arsenic, cadmium, strontium, and specially lead, were significantly higher in Moroccans than in Canarians, probably due to the intensive mining activity in this country. We also found significantly higher levels of the sum of REE and ME in Moroccans than in Canarians, possibly related to the inappropriate management of e-waste in this country. On the other hand, in the inhabitants of the Canary Islands we found higher levels of manganese, probably related to a higher degree of exposure to heavy traffic and exposure to Saharan dust of the people living in this region, and niobium and bismuth, probably related to the higher economic development in these islands. Our results indicate that the vicinity of both territories is not a major determinant of each other's contamination.
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Affiliation(s)
- Luis Alberto Henríquez-Hernández
- Toxicology Unit, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe s/n, 35016 Las Palmas, Spain
| | - Ana González-Antuña
- Toxicology Unit, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe s/n, 35016 Las Palmas, Spain
| | - Luis D Boada
- Toxicology Unit, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe s/n, 35016 Las Palmas, Spain; Spanish Biomedical Research Centre in Physiopathology of Obesity and Nutrition (CIBERObn), Paseo Blas Cabrera Felipe s/n, 35016 Las Palmas, Spain
| | - Cristina Carranza
- Infectious Diseases and Tropical Medicine Unit, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain; Medical Sciences and Surgery Department, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - José Luis Pérez-Arellano
- Infectious Diseases and Tropical Medicine Unit, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain; Medical Sciences and Surgery Department, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Maira Almeida-González
- Toxicology Unit, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe s/n, 35016 Las Palmas, Spain
| | - María Camacho
- Toxicology Unit, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe s/n, 35016 Las Palmas, Spain
| | - Manuel Zumbado
- Toxicology Unit, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe s/n, 35016 Las Palmas, Spain
| | | | - Manuel Tapia-Martín
- Haematology Service, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Octavio P Luzardo
- Toxicology Unit, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe s/n, 35016 Las Palmas, Spain; Spanish Biomedical Research Centre in Physiopathology of Obesity and Nutrition (CIBERObn), Paseo Blas Cabrera Felipe s/n, 35016 Las Palmas, Spain.
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16
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Critical issues underlying expenditures for adolescent idiopathic scoliosis surgery: questioning the surgical treatment motivation. J Pediatr 2018; 198:326-327. [PMID: 29699799 DOI: 10.1016/j.jpeds.2018.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 03/14/2018] [Indexed: 11/21/2022]
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17
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Evaluation of Blood Titanium Levels and Total Bone Contact Area of Dental Implants. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4121639. [PMID: 30046598 PMCID: PMC6038673 DOI: 10.1155/2018/4121639] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/11/2018] [Accepted: 05/02/2018] [Indexed: 12/01/2022]
Abstract
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.
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18
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Zhang J, Ma CJ, Wang HQ. Letter to the Editor. Tetrad issues exist regarding spinal fusion with pedicle screws and adjacent-segment disease. J Neurosurg Spine 2018; 29:227-228. [PMID: 29749799 DOI: 10.3171/2018.1.spine1813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jun Zhang
- 1Baoji Municipal Central Hospital, Baoji, Shaanxi Province, China
| | - Chi-Jiao Ma
- 2Ankang Hospital of Traditional Chinese Medicine, Ankang City, Shaanxi Province, China; and
| | - Hai-Qiang Wang
- 3Centre for Translational Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Zhang J, Ma CJ, Liu ZH, Wang HQ. Defining the Pros and Cons of AIS Surgery: Bringing Truth to the Neurosurgery Community and the Public. World Neurosurg 2018; 113:393-394. [PMID: 29702960 DOI: 10.1016/j.wneu.2018.01.209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Jun Zhang
- Spine Truth Studying Group, Department of Orthopaedics, Baoji Municipal Central Hospital, Baoji, Shaanxi Province, China
| | - Chi-Jiao Ma
- Spine Truth Studying Group, Department of Orthopedics, Ankang Hospital of Traditional Chinese Medicine, Shaanxi Province, China
| | - Zhi-Heng Liu
- Spine Truth Studying Group, Department of Orthopedics, Chinese PLA No. 451 Hospital, Xi'an, Shaanxi Province, China
| | - Hai-Qiang Wang
- Spine Truth Studying Group, Department of Orthopaedics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China; Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, China.
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20
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Koller D, Bramhall P, Devoy J, Goenaga-Infante H, Harrington CF, Leese E, Morton J, Nuñez S, Rogers J, Sampson B, Powell JJ. Analysis of soluble or titanium dioxide derived titanium levels in human whole blood: consensus from an inter-laboratory comparison. Analyst 2018; 143:5520-5529. [DOI: 10.1039/c8an00824h] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Exposure to titanium (Ti),viathe ingestion of pigment grade Ti dioxide (TiO2), is commonplace for westernised populations.
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Affiliation(s)
- D. Koller
- Biomineral Research Group
- Department of Veterinary Medicine
- University of Cambridge
- Cambridge
- UK
| | - P. Bramhall
- University Hospital of Wales TRACE ELEMENT LABORATORY
- Department of Medical Biochemistry and Immunology
- Cardiff
- UK
| | - J. Devoy
- INRS
- Unité de Génération d'atmosphères et de Chimie Analytique Toxicologique
- 54519 Vandoeuvre-lès-Nancy
- France
| | | | | | - E. Leese
- Health and Safety Executive
- Biological Monitoring
- Buxton
- UK
| | - J. Morton
- Health and Safety Executive
- Biological Monitoring
- Buxton
- UK
| | - S. Nuñez
- LGC Limited
- Inorganic Analysis
- Teddington
- UK
| | - J. Rogers
- University Hospital of Wales TRACE ELEMENT LABORATORY
- Department of Medical Biochemistry and Immunology
- Cardiff
- UK
| | - B. Sampson
- Charing Cross Hospital
- SAS Trace Element Laboratory
- London
- UK
| | - J. J. Powell
- Biomineral Research Group
- Department of Veterinary Medicine
- University of Cambridge
- Cambridge
- UK
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21
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Yilgor C, Efendiyev A, Akbiyik F, Demirkiran G, Senkoylu A, Alanay A, Yazici M. Metal Ion Release During Growth-Friendly Instrumentation for Early-Onset Scoliosis: A Preliminary Study. Spine Deform 2018; 6:48-53. [PMID: 29287817 DOI: 10.1016/j.jspd.2017.06.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 05/01/2017] [Accepted: 06/18/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Metal ions released from spinal instruments can cause localized debris and distribute systemically to settle on distant organs. Children with early-onset deformities live with metallic implants for a substantial amount of time. No research focused on metal distribution in growth-friendly instrumentations. The aim of this study was to compare age-matched growing rod (GR) and magnetically controlled growing rod (MCGR) groups to noninstrumented controls. METHODS The study was designed as a multicenter, prospective, cross-sectional case series. GR and MCGR applications of three institutions were included. A total of 52 children were enrolled. Blood samples were collected between December 2014 and February 2015. Biochemical serum analyses were performed to trace and quantify titanium, vanadium, aluminum, and boron. The GR group included 15 children. Mean age was 10.7 (range 6-15). MCGR group included 22 children. Mean age was 8.5 (range 2-13). Fifteen age-matched nonoperated children formed the control group. The mean age was 10.4 (range 5-15). One-way analysis of variance, Kruskal-Wallis, and Mann-Whitney U tests were used for comparisons. RESULTS The mean serum titanium level in control, GR, and MCGR groups were 2.8 ± 1.4, 7.3 ± 4.3, and 10.2 ± 6.8 μg/L, respectively. GR and MCGR group titanium levels were higher than controls' (p = .008 and p < .001). The mean serum vanadium level in control, GR, and MCGR groups were 0.2 ± 0.0, 0.2 ± 0.0, and 0.5 ± 0.5 μg/L, respectively. MCGR group vanadium level was higher than control (p < .001) and GR groups (p = .004). Mean serum levels in control, GR, and MCGR groups were, respectively, 5.4 ± 4.1, 8.1 ± 7.4, and 7.8 ± 5.1 μg/L for aluminum and 86.7 ± 2.7, 86.9 ± 2.5, and 85.0 ± 6.6 μg/L for boron. The distribution of aluminum and boron were similar across groups (p = .675 and p = .396). CONCLUSIONS Both GR and MCGR applications significantly release titanium and possibly aluminum. MCGR further releases vanadium. MCGR possibly releases more titanium than traditional GR. Time-dependent alterations of serum ion levels, structural properties of the MCGR device, and exposure caused by magnetic distraction processes warrant investigation.
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Affiliation(s)
- Caglar Yilgor
- Orthopedics and Traumatology, Acibadem Mehmet Ali Aydınlar University, İçerenköy Mh. No:32 Kerem Aydınlar Kampüsü, Kayışdağı Cd., 34752 Ataşehir, Turkey
| | - Ayaz Efendiyev
- Orthopedics and Traumatology, Hacettepe University, 06100 Sihhiye, Ankara, Turkey
| | - Filiz Akbiyik
- Medical Biochemistry, Hacettepe University, 06100 Sihhiye, Ankara, Turkey
| | - Gokhan Demirkiran
- Orthopedics and Traumatology, Hacettepe University, 06100 Sihhiye, Ankara, Turkey
| | - Alpaslan Senkoylu
- Orthopedics and Traumatology, Gazi University, Emniyet Mahallesi, 06560 Yenimahalle, Ankara, Turkey
| | - Ahmet Alanay
- Orthopedics and Traumatology, Acibadem Mehmet Ali Aydınlar University, İçerenköy Mh. No:32 Kerem Aydınlar Kampüsü, Kayışdağı Cd., 34752 Ataşehir, Turkey
| | - Muharrem Yazici
- Orthopedics and Traumatology, Hacettepe University, 06100 Sihhiye, Ankara, Turkey.
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A randomized double-blinded clinical trial to evaluate the safety and efficacy of a novel superelastic nickel-titanium spinal rod in adolescent idiopathic scoliosis: 5-year follow-up. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:327-339. [PMID: 28776134 DOI: 10.1007/s00586-017-5245-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 07/12/2017] [Accepted: 07/27/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of a superelastic shape-memory alloy (SNT) rod used in the treatment of adolescent idiopathic scoliosis (AIS). METHODS AIS Patients with Lenke 1 curves undergoing fusion surgery were randomized (1:1) at the time of surgery to receive either the SNT or a conventional titanium alloy (CTA) rod. Radiographs were obtained preoperatively and postoperatively up to 5 years of follow-up. Parameters assessed included coronal and sagittal Cobb angles, and overall truncal and shoulder balance. Sagittal profiles were subcategorized into Types A (<20°), B (20-40°), and C (>40°). RESULTS Twenty-four patients with mean age of 15 years were recruited. A total of 87.0% of subjects were followed up till postoperative 5 years, but all patients had minimum 2 years of follow-up. The fulcrum-bending correction index for the SNT group was 113% at postoperative day 4 and 127% at half-year, while the CTA group was 112% at postoperative day 4 and only 106% at half-year. In terms of sagittal profile, the SNT group moved toward type B profile at half-year follow-up with a mean correction of 7.6°, while no significant change was observed in the CTA group (-0.7°). Nickel levels remained normal, and there were no complications. CONCLUSIONS This is the first randomized clinical trial of a novel SNT rod for treating patients with AIS, noting it to be safe and has potential to gradually correct scoliosis over time. This study serves as a pilot and platform to properly power future large-scale studies to demonstrate efficacy and superiority.
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Brembilla C, Lanterna LA, Giampreti A, Bernucci C. Letter to the Editor concerning "Spinal metallosis: a systematic review" by Goldenberg Y, Tee JW, Salinas-La Rosa CM, Murphy M (Eur Spine J; 2016, 25:1467-1473). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2218-2219. [PMID: 28612192 DOI: 10.1007/s00586-017-5189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 06/10/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Carlo Brembilla
- Department of Neurosurgery, Pope John XXIII Hospital, WHO Square No. 1, 24127, Bergamo, Italy.
| | - Luigi Andrea Lanterna
- Department of Neurosurgery, Pope John XXIII Hospital, WHO Square No. 1, 24127, Bergamo, Italy
| | - Andrea Giampreti
- Poison Center Clinical Toxicology, Pope John XXIII Hospital, WHO Square No. 1, 24127, Bergamo, Italy
| | - Claudio Bernucci
- Department of Neurosurgery, Pope John XXIII Hospital, WHO Square No. 1, 24127, Bergamo, Italy
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Corrosion of Harrington rod in idiopathic scoliosis: long-term effects. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017. [PMID: 28624897 DOI: 10.1007/s00586-017-5183-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Metal implants have been used to treat adolescent idiopathic scoliosis since the 1960s. Only recently, however, it has the issue of metal-bone breakdown secondary to metal corrosion in situ come to light, raising concerns of possible long-term complications from the resulting metallosis and inflammation of spinal tissues. We present a case of a patient with neurological deficit, pain, and disability with Harrington rod in place for over 30 years, to bring attention to the issue of bio-corrosion of metal implants and its effect on human tissue. We call attention to the need for protocols to better diagnose and treat these patients. METHODS We provide a complete review of the history and clinical manifestations as well as serum metal, X-ray, and CT/myelogram test results. RESULTS A 52-year-old female with spinal fusion and Harrington rod presents with pain, lymphedema, disability, and neurological deficits including thoracic outlet syndrome, hyperreflexia, peripheral muscle weakness and atrophy, hypertonicity, Raynaud's phenomenon, and balance and gait abnormalities. Serum chromium levels were elevated (26.73 nmol). X-rays showed no evidence of rod breakdown. Serial X-rays can demonstrate subtle corrosive changes but were not available. Adhesive arachnoiditis was diagnosed via CT/myelogram. CONCLUSION We hypothesize that bio-corrosion is present in this case and that it is associated with intraspinal metallosis. Trauma secondary to a motor vehicle accident, as well as arachnoiditis, and their possible effects on this case are outlined. Challenges in proper diagnosis and management are discussed.
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Serum Metal Concentrations in Patients With Titanium Ceramic Composite Cervical Disc Replacements. Spine (Phila Pa 1976) 2017; 42:366-371. [PMID: 27323223 DOI: 10.1097/brs.0000000000001745] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective longitudinal study. OBJECTIVE The serum titanium (Ti) concentrations were examined in patients implanted with a PRESTIGE LP Cervical Disc System (Medtronic, Inc., Memphis, TN). The metal-on-metal disc with ball-in-trough articulation is made of titanium alloy/titanium carbide composite (Ti-6Al-4 V/TiC). SUMMARY OF BACKGROUND DATA Cervical disc arthroplasty provides a motion-preserving treatment alternative to anterior cervical discectomy and fusion for degenerative cervical disc disease. The articulating surfaces have a tendency to generate in vivo wear in the form of insoluble particulates (debris) and soluble metal ions. Not much information is available on the long-term metal concentrations observed in cervical disc arthroplasty and how these compare with the metal concentrations in Ti-based posterior fixation devices and other joint replacement implants. METHODS Thirty patients were enrolled after strict exclusion criteria that included no previous permanent metal implants and no professional exposure to metal particles. High-resolution inductively coupled plasma-mass spectrometry was used to assay blood serum titanium concentrations preoperatively and at 3, 6, 12, 24, 36, 60, and 84 months after surgery. The detection limit for Ti was 0.2 ng/mL. The Friedman test was used to make longitudinal statistical comparisons. RESULTS The median serum Ti concentrations determined preoperatively, and at 3, 6, 12, 24, 36, 60, and 84 months were 0.10, 1.22, 1.15, 1.27, 1.21, 1.46, 1.34, and 1.42 ng/mL, respectively. The serum Ti concentrations at all postoperative time points were significantly higher than that at the preoperative time point (Friedman P < 0.01). CONCLUSION The long-term postoperative serum Ti concentrations were significantly higher than the preoperative concentrations. The observed serum Ti concentrations in this study are lower than the reported concentrations in patients receiving posterior spinal instrumentation and metal or ceramic-on-polyethylene hip prostheses with Ti-alloy based stems and acetabular components. LEVEL OF EVIDENCE 3.
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A Comparison of Patient-Reported Outcome Measures Following Different Treatment Approaches for Adolescents with Severe Idiopathic Scoliosis: A Systematic Review. Asian Spine J 2016; 10:1170-1194. [PMID: 27994796 PMCID: PMC5165010 DOI: 10.4184/asj.2016.10.6.1170] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/30/2016] [Accepted: 04/03/2016] [Indexed: 11/08/2022] Open
Abstract
Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine which is usually not symptomatic and which can progress during growth and cause a surface deformity. In adulthood, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased. Although surgery is usually recommended for curvatures exceeding 40° to 50° to stop curvature progression, recent reviews have shed some light on the long-term complications of such surgery and to the lack of evidence for such complicated procedures within the scientific literature. Furthermore, a number of patients are very fearful of having surgery and refuse this option or live in countries where specialist scoliosis surgery is not available. Other patients may be unable to afford the cost of specialist scoliosis surgery. For these patients the only choice is an alternative non-surgical treatment option. To examine the impact of different management options in patients with severe AIS, with a focus on trunk balance, progression of scoliosis, cosmetic issues, quality of life, disability, psychological issues, back pain, and adverse effects, at both the short-term (a few months) and the long-term (over 20 years). We searched CENTRAL, MEDLINE, EMBASE, CINHAL and two other databases up to January 2016 with no language limitations. We also checked the reference lists of relevant articles and conducted an extensive hand search of the grey literature. We searched for randomised controlled trials as well as prospective and retrospective controlled trials comparing spinal fusion surgery with no treatment or conservative treatment in AIS patients with a Cobb angle greater than 40°. We did not identify any evidence of superiority of effectiveness of operative compared to nonoperative interventions for patients with severe AIS. Within the present literature there is no clear evidence to suggest that a specific type of treatment is superior to other types of treatment.
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Metal concentrations in the blood and tissues after implantation of titanium growth guidance sliding instrumentation. Spine J 2016; 16:380-8. [PMID: 26656164 DOI: 10.1016/j.spinee.2015.11.040] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 08/07/2015] [Accepted: 11/18/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Growth guidance sliding treatment devices, such as Shilla (Medtronic, Minneapolis, MN USA) or LSZ-4D (CONMET, Moscow, Russia), used for the treatment of scoliosis in children who have high growth potential have unlocked fixtures that allow rods to slide during growth of the spine, which avoids periodical extensions. However, the probability of clinical complications associated with metallosis after implantation of such devices is poorly understood. The content of metal ions in the blood and tissues of pediatric patients treated for scoliosis using fusionless growth guidance sliding instrumentation has not yet been investigated. PURPOSE The aim of the present study was to measure the content of metal ions in the blood and tissues surrounding the implanted growth guidance sliding LSZ-4D devices made of titanium alloy (Ti6Al4V), and to identify the incidence of metallosis-associated clinical complications in some patients with these devices. STUDY DESIGN This is a one-center, case-control retrospective study. PATIENTS SAMPLE The study group included 25 patients with high growth potential (22 females, 3 males; average age at primary surgery for scoliosis treatment is 11.4±1.2 years old) who had sliding growth guidance instrumentation LSZ-4D (CONMET) implanted on 13 (range: 10-16) spine levels for 6±2 years. The LSZ-4D device was made from titanium alloy Ti6Al4V and consisted of two rectangular section rods and fixture elements. Locked fixtures were used on one spinal level, whereas the others were unlocked (sliding). The control group consisted of 13 patients (12 females and 1 male; 11±1.2 years old) without any implanted devices. OUTCOME MEASURES The content of Ti, Al, and V metal ions in the whole blood and tissues around the implanted device was measured. The incidences of metallosis-associated complications in the study group were recorded. METHODS Metal ion content was measured by the inductively coupled mass spectrometry method on quadrupolar NexION 300D (PerkinElmer Inc, Shelton, CT, USA). RESULTS Five of 25 patients in the study group developed metallosis-associated complications (two sinuses and three seroma in the lumbar part of the spine). Revisions were carried out in two of these patients. Ninety percent of the patients in the study group had increased content of Ti and V ions in the blood (2.8 and 4 times, respectively). Median content of Ti ions in soft tissues adjacentto implanted sliding device was more than 1,500-fold higher than that of the control group. These levels are much higher than previously reported for spinal instrumentation. CONCLUSIONS Increased content of Ti and V ions in the blood and especially in tissues around the titanium growth guidance sliding device LSZ-4D accompanied by clinical manifestations (seroma and sinuses) indicates the importance of improving wear resistance of such instrumentation with the coatings and the necessity to exchange sliding instrumentation once the child is fully grown.
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Golasik M, Herman M, Piekoszewski W. Toxicological aspects of soluble titanium – a review of in vitro and in vivo studies. Metallomics 2016; 8:1227-1242. [DOI: 10.1039/c6mt00110f] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Atila A, Halici Z, Cadirci E, Karakus E, Palabiyik SS, Ay N, Bakan F, Yilmaz S. Study of the boron levels in serum after implantation of different ratios nano-hexagonal boron nitride–hydroxy apatite in rat femurs. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2016; 58:1082-9. [DOI: 10.1016/j.msec.2015.09.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 07/29/2015] [Accepted: 09/08/2015] [Indexed: 12/24/2022]
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Local and systemic metal ion release occurs intraoperatively during correction and instrumented spinal fusion for scoliosis. J Child Orthop 2015; 9:39-43. [PMID: 25589286 PMCID: PMC4340846 DOI: 10.1007/s11832-015-0631-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/03/2015] [Indexed: 02/03/2023] Open
Abstract
STUDY DESIGN Prospective pilot study. OBJECTIVES The aim of this study was to measure titanium, niobium and aluminium levels in various intraoperative and postoperative samples to determine patterns of metal ion release that occur within the first month following instrumented spinal fusion. Raised serum metal ion levels are reported following instrumented spinal fusion in adolescent idiopathic scoliosis. The exact topological origin and chronology of metal ion release remains conjectural. Recent literature suggests an immediate rise in serum metal levels within the first postoperative week. METHODS Titanium, niobium and aluminium levels were measured before, during and after surgery in serum and local intraoperative fluid samples obtained from two pediatric patients undergoing posterior correction and instrumentation for scoliosis. RESULTS Measurable metal ion levels were detected in all local samples obtained from wound irrigation fluid, cell saver blood, and fluid that immersed metal universal reduction screw tabs. Postoperative serum metal ion levels were elevated compared to baseline preoperative levels. In general, metal ion levels were considerably higher in the intraoperative fluid samples compared to those observed in the serum levels. CONCLUSION Our findings of contextually high metal ion concentrations in intraoperative and early postoperative samples provide further empirical support of a 'putting-in' phenomenon of metal ion release following instrumented spinal fusion. This challenges existing beliefs that metal ion release occurs during an intermediate 'wearing-in' phase. We recommend thorough irrigation of the operative site prior to wound closure to dilute and remove intraoperative metal ion debris. Possibilities of filtering trace metal ions from cell saver content may be considered.
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Stejskal V, Reynolds T, Bjørklund G. Increased frequency of delayed type hypersensitivity to metals in patients with connective tissue disease. J Trace Elem Med Biol 2015; 31:230-6. [PMID: 25636536 DOI: 10.1016/j.jtemb.2015.01.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/05/2015] [Accepted: 01/06/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Connective tissue disease (CTD) is a group of inflammatory disorders of unknown aetiology. Patients with CTD often report hypersensitivity to nickel. We examined the frequency of delayed type hypersensitivity (DTH) (Type IV allergy) to metals in patients with CTD. METHODS Thirty-eight patients; 9 with systemic lupus erythematosus (SLE), 16 with rheumatoid arthritis (RA), and 13 with Sjögren's syndrome (SS) and a control group of 43 healthy age- and sex-matched subjects were included in the study. A detailed metal exposure history was collected by questionnaire. Metal hypersensitivity was evaluated using the optimised lymphocyte transformation test LTT-MELISA(®) (Memory Lymphocyte Immuno Stimulation Assay). RESULTS In all subjects, the main source of metal exposure was dental metal restorations. The majority of patients (87%) had a positive lymphocyte reaction to at least one metal and 63% reacted to two or more metals tested. Within the control group, 43% of healthy subjects reacted to one metal and only 18% reacted to two or more metals. The increased metal reactivity in the patient group compared with the control group was statistically significant (P<0.0001). The most frequent allergens were nickel, mercury, gold and palladium. CONCLUSIONS Patients with SLE, RA and SS have an increased frequency of metal DTH. Metals such as nickel, mercury and gold are present in dental restorative materials, and many adults are therefore continually exposed to metal ions through corrosion of dental alloys. Metal-related DTH will cause inflammation. Since inflammation is a key process in CTDs, it is possible that metal-specific T cell reactivity is an etiological factor in their development. The role of metal-specific lymphocytes in autoimmunity remains an exciting challenge for future studies.
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Affiliation(s)
- Vera Stejskal
- Wenner-Gren Institute for Experimental Biology, University of Stockholm, Stockholm, Sweden.
| | - Tim Reynolds
- Chemical Pathology, Burton Hospitals NHS Foundation Trust, Burton upon Trent, United Kingdom
| | - Geir Bjørklund
- Council for Nutritional and Environmental Medicine, Mo i Rana, Norway
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Cundy TP, Cundy WJ, Antoniou G, Sutherland LM, Freeman BJC, Cundy PJ. Serum titanium, niobium and aluminium levels two years following instrumented spinal fusion in children: does implant surface area predict serum metal ion levels? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:2393-2400. [DOI: 10.1007/s00586-014-3279-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 03/13/2014] [Indexed: 11/28/2022]
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A novel pedicle screw with mobile connection: a pilot study. BIOMED RESEARCH INTERNATIONAL 2014; 2014:841958. [PMID: 24724103 PMCID: PMC3958777 DOI: 10.1155/2014/841958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 01/22/2014] [Accepted: 01/28/2014] [Indexed: 11/20/2022]
Abstract
To prevent adjacent disc problems after spinal fusion, a pedicle screw with a mobile junction between the head and threaded shaft was newly developed. The threaded shaft of the screw has 10 degrees mobility in all directions, but its structure is to prevent abnormal translation and tilting. This screw was evaluated as follows: (1) endurance test: 106 times rotational stress was applied; (2) biological reactions: novel screws with a mobile head and conventional screws with a fixed head were inserted into the bilateral pedicles of the L3, L4, and L5 in two mini pigs with combination. Eight months after surgery, vertebral units with the screw rod constructs were collected. After CT scan, the soft and bony tissues around the screws were examined grossly and histologically. As a result, none of the screws broke during the endurance test stressing. The mean amount of abrasion wear was 0.0338 g. In the resected mini pig section, though zygapophyseal joints between fixed-head screws showed bony union, the amount of callus in the zygapophyseal joints connected with mobile-head screws was small, and joint space was confirmed by CT. No metalloses were noted around any of the screws. Novel screws were suggested to be highly durable and histologically safe.
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