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Ude CC, Schmidt SJ, Laurencin S, Shah S, Esdaille J, Kan HM, Holt BD, Arnold AM, Wolf ME, Nair LS, Sydlik SA, Laurencin CT. Hyaluronic acid-British anti-Lewisite as a safer chelation therapy for the treatment of arthroplasty-related metallosis. Proc Natl Acad Sci U S A 2023; 120:e2309156120. [PMID: 37903261 PMCID: PMC10636327 DOI: 10.1073/pnas.2309156120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/17/2023] [Indexed: 11/01/2023] Open
Abstract
Cobalt-containing alloys are useful for orthopedic applications due to their low volumetric wear rates, corrosion resistance, high mechanical strength, hardness, and fatigue resistance. Unfortunately, these prosthetics release significant levels of cobalt ions, which was only discovered after their widespread implantation into patients requiring hip replacements. These cobalt ions can result in local toxic effects-including peri-implant toxicity, aseptic loosening, and pseudotumor-as well as systemic toxic effects-including neurological, cardiovascular, and endocrine disorders. Failing metal-on-metal (MoM) implants usually necessitate painful, risky, and costly revision surgeries. To treat metallosis arising from failing MoM implants, a synovial fluid-mimicking chelator was designed to remove these metal ions. Hyaluronic acid (HA), the major chemical component of synovial fluid, was functionalized with British anti-Lewisite (BAL) to create a chelator (BAL-HA). BAL-HA effectively binds cobalt and rescues in vitro cell vitality (up to 370% of cells exposed to IC50 levels of cobalt) and enhances the rate of clearance of cobalt in vivo (t1/2 from 48 h to 6 h). A metallosis model was also created to investigate our therapy. Results demonstrate that BAL-HA chelator system is biocompatible and capable of capturing significant amounts of cobalt ions from the hip joint within 30 min, with no risk of kidney failure. This chelation therapy has the potential to mitigate cobalt toxicity from failing MoM implants through noninvasive injections into the joint.
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Affiliation(s)
- Chinedu C. Ude
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Stephen J. Schmidt
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Samuel Laurencin
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Shiv Shah
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
- Department of Chemical and Biomolecular Engineering, University of Connecticut, Storrs, CT06269
| | - Jayson Esdaille
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Ho-Man Kan
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Brian D. Holt
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Anne M. Arnold
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Michelle E. Wolf
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Lakshmi S. Nair
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
- Department of Chemical and Biomolecular Engineering, University of Connecticut, Storrs, CT06269
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT06269
- Department of Materials Science and Engineering, University of Connecticut, Storrs, CT06269
- Institute of Materials Science, University of Connecticut, Storrs, CT06269
| | - Stefanie A. Sydlik
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA15213
| | - Cato T. Laurencin
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
- Department of Chemical and Biomolecular Engineering, University of Connecticut, Storrs, CT06269
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT06269
- Department of Materials Science and Engineering, University of Connecticut, Storrs, CT06269
- Institute of Materials Science, University of Connecticut, Storrs, CT06269
- Department of Craniofacial Sciences, School of Dental Medicine, University of Connecticut Health, Farmington, CT06030
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Wan ZY, Shan H, Liu TF, Song F, Zhang J, Liu ZH, Ma KL, Wang HQ. Emerging Issues Questioning the Current Treatment Strategies for Lumbar Disc Herniation. Front Surg 2022; 9:814531. [PMID: 35419406 PMCID: PMC8999845 DOI: 10.3389/fsurg.2022.814531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 03/04/2022] [Indexed: 11/26/2022] Open
Abstract
Lumbar disc herniation is among the common phenotypes of degenerative lumbar spine diseases, significantly affecting patients' quality of life. The practice pattern is diverse. Choosing conservative measures or surgical treatments is still controversial in some areas. For those who have failed conservative treatment, surgery with or without instrumentation is recommended, causing significant expenditures and frustrating complications, that should not be ignored. In the article, we performed a literature review and summarized the evidence by subheadings to unravel the cons of surgical intervention for lumbar disc herniation. There are tetrad critical issues about surgical treatment of lumbar disc herniation, i.e., favorable natural history, insufficient evidence in a recommendation of fusion surgery for patients, metallosis, and implant removal. Firstly, accumulating evidence reveals immune privilege and auto-immunity hallmarks of human lumbar discs within the closed niche. Progenitor cells within human discs further expand the capacity with the endogenous repair. Clinical watchful follow-up studies with repeated diagnostic imaging reveal spontaneous resolution for lumbar disc herniation, even calcified tissues. Secondly, emerging evidence indicates long-term complications of lumbar fusion, such as adjacent segment disease, pseudarthrosis, implant failure, and sagittal spinal imbalance, which get increasing attention. Thirdly, systemic and local reactions (metallosis) for metal instrumentation have been noted with long-term health concerns and toxicity. Fourthly, the indications and timing for spinal implant removal have not reached a consensus. Other challenging issues include postoperative lumbar stiffness. The review provided evidence from a negative perspective for surgeons and patients who attempt to choose surgical treatment. Collectively, the emerging underlying evidence questions the benefits of traditional surgery for patients with lumbar disc herniation. Therefore, the long-term effects of surgery should be closely observed. Surgical decisions should be made prudently for each patient.
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Affiliation(s)
- Zhong Y. Wan
- Department of Orthopedics, The Seventh Medical Center of General Hospital of People's Liberation Army (PLA), Beijing, China
| | - Hua Shan
- Institute of Integrative Medicine, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Tang F. Liu
- Institute of Integrative Medicine, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Fang Song
- Department of Stomatology, The Specialty Medical Center Rocket Force of People's Liberation Army (PLA), Beijing, China
| | - Jun Zhang
- Department of Orthopedics, Baoji Central Hospital, Baoji, China
| | - Zhi H. Liu
- Department of Cardiac Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Kun L. Ma
- Department of Orthopedics, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Hai Q. Wang
- Institute of Integrative Medicine, Shaanxi University of Chinese Medicine, Xi'an, China
- *Correspondence: Hai Q. Wang ;
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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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Liu G, Wang X, Zhou X, Zhang L, Mi J, Shan Z, Huang B, Chen Z, Chen Z. Modulating the cobalt dose range to manipulate multisystem cooperation in bone environment: a strategy to resolve the controversies about cobalt use for orthopedic applications. Theranostics 2020; 10:1074-1089. [PMID: 31938052 PMCID: PMC6956813 DOI: 10.7150/thno.37931] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/21/2019] [Indexed: 12/21/2022] Open
Abstract
The paradoxical effect of cobalt on biological processes has aroused controversy regarding the application of cobalt-based biomaterials in bone regeneration. Tuning the dose range of cobalt ions may be a valid strategy to resolve the controversies about cobalt use for orthopedic applications. Recent progress in bone biology has highlighted the effects of multisystem cooperation (especially of osteoimmune, skeletal, and vascular systems) on bone dynamics. Before the application of this dose-tuning strategy, a deeper understanding of its dose-dependent effect on the cooperation of osteoimmune, skeletal, and vascular systems is needed. However, due to the difficulties with investigating the interaction of multiple systems in vitro, the multimodal effects of cobalt on bone homeostasis were investigated here, in an in vivo scenario. Methods: In vitro CCK8 assay and cytoskeletal staining were preformed to detecte the cell cytotoxic reaction in response to 0.1-100 ppm cobalt stimulation. Blood clot containing 0.1 to 5 ppm of cobalt were implanted in the rat calvarium defect. The gene profile of osteoimmune, skeletal, and vascular system as well as the systemic toxicity were evaluated via RT-qPCR, histological analysis and inductively coupled plasma mass spectrometry. The bone regeneration, osteoclastogenesis and vascularization were assessed by micro-ct and histological analysis. Results: Cobalt concentration below 5 ppm did not cause cell toxicity in vitro. No systemic toxicity was observed in vivo at 0.1-5 ppm cobalt concentration. It was found that the early cytokine profiles of the multiple interacting systems were different in response to different cobalt doses. Most of the anti-inflammatory, osteogenic, and proangiogenic factors were upregulated in the 1 ppm cobalt group at the early stage. In the late stage, the 1ppm group was most superior in bone regenerative effect while the 5 ppm group displayed the strongest osteoclastogenesis activity. Conclusions: The 1 ppm concentration of cobalt yielded the most favorable cooperation of the osteoimmune, skeletal, and vascular systems and subsequently optimal bone regeneration outcomes. Tuning the cobalt dose range to manipulate the cooperation of osteoimmune, skeletal, and vascular systems could be a promising and valuable strategy to prevent paradoxical effects of cobalt while preserving its beneficial effects.
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Affiliation(s)
- Guanqi Liu
- Institute of Stomatology and Department of Oral Implantology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Xiaoshuang Wang
- Institute of Stomatology and Department of Oral Implantology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Xuan Zhou
- Institute of Stomatology and Department of Oral Implantology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Linjun Zhang
- Institute of Stomatology and Department of Oral Implantology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Jiaomei Mi
- Institute of Stomatology and Department of Oral Implantology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Zhengjie Shan
- Institute of Stomatology and Department of Oral Implantology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Baoxin Huang
- Institute of Stomatology and Department of Oral Implantology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Zhuofan Chen
- Zhujiang New Town Clinic, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Zetao Chen
- Institute of Stomatology and Department of Oral Implantology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
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Schultzel M, Klein CM, Demirjian M, Blout C, Itamura JM. Incidence of Metal Hypersensitivity in Orthopedic Surgical Patients Who Self-Report Hypersensitivity History. Perm J 2019; 24:19.091. [PMID: 31852052 DOI: 10.7812/tpp/19.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Metallic implants are integral to the practice of orthopedic surgery. Delayed-onset T-cell-mediated metal hypersensitivity (diagnosed by patch testing) is reported in 10% to 17% of the general population. Inconclusive evidence exists about the role of metal hypersensitivity in persistently painful or aseptic loosening of arthroplasties. Literature suggests that preoperative patch testing may influence surgical practice. OBJECTIVE To determine the incidence of metal hypersensitivity in orthopedic surgical patients who self-report hypersensitivity and to characterize which metals are most commonly implicated. METHODS A retrospective chart review of patients from a single surgeon's practice was conducted during a 1-year period. All patients were questioned about metal hypersensitivity history; all patients who responded affirmatively were sent for patch testing for specific metals. RESULTS Only 41 (4.9%) of 840 patients self-reported any metal hypersensitivity. Of these, 34 (83%) were patch-test positive to 1 or more metals. There were 27 whose test results were positive for nickel, 4 each to cobalt or gold thiosulfate, and 1 each to tin or titanium. Seven patients had positive results to multiple metals, all of whom were also nickel hypersensitive. Six patients had metal orthopedic implants before patch testing, and 4 (67%) tested positively to a metal in their implant. CONCLUSION Metal hypersensitivity can be concerning for treating surgeons and patients. Greater awareness of a history to hypersensitivity may prevent patient exposure to implants containing metals that may cause hypersensitivity. Non-metal-containing or nonreactive metal implants are an option for patients in whom metal hypersensitivity is suspected or confirmed.
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Affiliation(s)
- Mark Schultzel
- Southern California Permanente Medical Group, Orthopedic Medical Group of San Diego, Synergy Orthopedic Specialists Medical Group, San Diego
| | - Christopher M Klein
- Kerlan-Jobe Orthopaedic Clinic, White Memorial Medical Center, Cedars-Sinai Medical Center, Keck School of Medicine, Los Angeles, CA
| | - Marine Demirjian
- Department of Allergy and Immunology, University of California, Los Angeles
| | - Colin Blout
- Kerlan-Jobe Orthopaedic Clinic, White Memorial Medical Center, Cedars-Sinai Medical Center, Keck School of Medicine, Los Angeles, CA
| | - John M Itamura
- Kerlan-Jobe Orthopaedic Clinic, White Memorial Medical Center, Cedars-Sinai Medical Center, Keck School of Medicine, Los Angeles, CA
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Sangaletti R, Spreafico A, Barbieri F, Ferrari R, Castelli CC. Metal ion trend in patients with metal-on-metal total hip arthroplasty: a 10-year prospective study. Hip Int 2018; 28:43-47. [PMID: 30755113 DOI: 10.1177/1120700018812991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION: There have been reported adverse reactions in patients with large head metal-on-metal hip arthroplasty, therefore metal particle debris are a cause for concern. The aim of this study was to evaluate the release trend of metal ions and the correlated variables. METHODS: 54 patients were prospectively enrolled into the study from 2004 to 2006. All patients had 36-mm metal head, Pinnacle acetabular component, Summit stem and Ultamet CoCr alloy liner (Depuy Inc.), and underwent clinical and radiological management. The haematic concentration of Cr-Co at 0, 6, 12, 24, 60 and 120 months after the implantation was analysed in a sub-cohort of 34 patients. RESULTS: 10-year revision rate for each case was 8.9%. The average concentration of Co at 120 months was 3.12 μg/L (median 2.20) with 53% values >2 μg/L and 1 >7 μg/L. After 6 months the median levels of Cr and Co were higher than time 0 ( p < 0.0001); no significant differences were found between 6 and 24 months; while Co had significant increase between 60 and 120 months ( p = 0.002). Overweight, University of California at Los Angeles (UCLA) >9 and <50 years old patients have significantly higher circulating metal ions. DISCUSSION: This is 1 of the few prospective studies on the argument. The revision rate is conforming to records. Our data shows ionic concentration is not predictive of revision or adverse reaction to metals. We described a 3-phase trend for Co probably due to the loss of integrity of the surfaces.
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Affiliation(s)
- Rudy Sangaletti
- Department of Orthopaedics and Traumatology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Andrea Spreafico
- Department of Orthopaedics and Traumatology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Flavio Barbieri
- Department of Orthopaedics and Traumatology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Roberto Ferrari
- Department of Orthopaedics and Traumatology, ASST Papa Giovanni XXIII, Bergamo, Italy
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Acetabular Cups in 60 mm Metal-on-Metal Bearings Subjected to Dynamic Edge-Loading with 70° Peak-Inclination in 10-Million Cycle Simulator Study. LUBRICANTS 2017. [DOI: 10.3390/lubricants6010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Ho JH, Leikin JB, Dargan PI, Archer JRH, Wood DM, Brent J. Metal-on-Metal Hip Joint Prostheses: a Retrospective Case Series Investigating the Association of Systemic Toxicity with Serum Cobalt and Chromium Concentrations. J Med Toxicol 2017; 13:321-328. [PMID: 28900863 PMCID: PMC5711759 DOI: 10.1007/s13181-017-0629-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/09/2017] [Accepted: 08/17/2017] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION There have been concerns about prosthesis failure and the potential for systemic toxicity due to release of cobalt and chromium from metal-on-metal hip joint prostheses (MoM-HP). There is conflicting evidence on whether there is a correlation between higher cobalt and chromium concentrations and systemic toxicity. METHODS We undertook a retrospective review of consecutive patients with MoM-HP referred for outpatient review in toxicology clinics in London, UK, and in the USA recorded in the Toxicology Investigators Consortium (ToxIC) Registry from June 2011 to June 2015. RESULTS Thirty-one cases were identified; the median (IQR) serum cobalt concentration was 10.0 (3.8-32.8) mcg/L, and the median (IQR) serum chromium concentration was 6.9 (3.7-18.7) mcg/L. Twenty-three (74.2%) had symptoms, most commonly lethargy, hearing loss, and tinnitus. The odds ratios of symptomatic/asymptomatic patients for metal ion concentrations above/below 7 mcg/L were 1.87 (95% CI 0.37-9.57, p = 0.45) and 0.60 (95% CI 0.10-3.50, p = 0.57) for cobalt and chromium, respectively. Two (6.5%) patients with systemic cobalt toxicity had median (IQR) serum cobalt concentrations significantly higher than those without systemic features (630.4 [397.6-863.2] mcg/L versus 9.8 [2.9-16.4] mcg/L; p = 0.017). However, overall, there were no differences between cobalt (p = 0.38) or chromium (p = 0.92) concentrations between symptomatic and asymptomatic patients and no clinical features or investigation results correlated with cobalt or chromium concentration. CONCLUSION Two (6.5%) of 31 individuals referred for assessment of MoM-HP were diagnosed with systemic cobalt toxicity. However, despite a high prevalence of reported symptoms, neither symptoms nor investigation results correlated with serum cobalt or chromium concentrations.
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Affiliation(s)
- James H Ho
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jerrold B Leikin
- Medical Toxicology, Glenbrook Hospital, NorthShore University Health System-OMEGA, Glenview, IL, USA
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK.
- Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jeffrey Brent
- School of Medicine, University of Colorado, Aurora, CO, USA
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Granchi D, Savarino LM, Ciapetti G, Baldini N. Biological effects of metal degradation in hip arthroplasties. Crit Rev Toxicol 2017; 48:170-193. [PMID: 29130357 DOI: 10.1080/10408444.2017.1392927] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metals and metal alloys are the most used materials in orthopedic implants. The focus is on total hip arthroplasty (THA) that, though well tolerated, may be associated with local and remote adverse effects in the medium-long term. This review aims to summarize data on the biological consequences of the metal implant degradation that have been attributed predominantly to metal-on-metal (MoM) THA. Local responses to metals consist of a broad clinical spectrum ranging from small asymptomatic tissue lesions to severe destruction of bone and soft tissues, which are designated as metallosis, adverse reactions to metal debris (ARMD), aseptic lymphocytic vasculitis associated lesion (ALVAL), and pseudotumors. In addition, the dissemination of metal particles and ions throughout the body has been associated with systemic adverse effects, including organ toxicity, cancerogenesis, teratogenicity, and immunotoxicity. As proved by the multitude of studies in this field, metal degradation may increase safety issues associated with THA, especially with MoM hip systems. Data collection regarding local, systemic and long-term effects plays an essential role to better define any safety risks and to generate scientifically based recommendations.
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Affiliation(s)
- Donatella Granchi
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Lucia Maria Savarino
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Gabriela Ciapetti
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Nicola Baldini
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy.,b Department of Biomedical and Neuromotor Science , University of Bologna , Bologna , Italy
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Hartmann D, Letulé V, Schneider JJ, Flaig MJ. [Metal implant sensitivity: clinical and histological presentation]. Hautarzt 2017; 67:373-9. [PMID: 27090521 DOI: 10.1007/s00105-016-3790-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Metal implant sensitivity (intolerance) can cause pain, reduced mobility, loosening of the implant and skin rashes. Knowledge of differential diagnoses, histology and appropriate diagnostics are essential for proper diagnosis. To outline typical clinical signs and histology in metal-implant-associated skin lesions we present three exemplary patients from our implant allergy outpatient department and give an overview of the current literature regarding metal implant sensitivity. In patients with a negative patch test the lymphocyte transformation test may reveal metal sensitization. Even "pure" titanium alloys may contain traces of nickel. The histology of implant-associated skin reactions goes from teleangiectatic postimplantation erythema to eczema and vasculitis. Based on the synopsis of history, clinical picture, allergological testing and histology, metal implant sensitivity can be diagnosed more precisely.
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Affiliation(s)
- D Hartmann
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität München, Frauenlobstr. 9-11, München, Deutschland.
| | - V Letulé
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität München, Frauenlobstr. 9-11, München, Deutschland
| | - J J Schneider
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität München, Frauenlobstr. 9-11, München, Deutschland
| | - M J Flaig
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität München, Frauenlobstr. 9-11, München, Deutschland
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Abstract
Cobalt can cause a distinctive, rapidly progressive and reversible depression of cardiac systolic function, which is readily distinguished from other causes of cardiomyopathy. Patients present with the subacute onset of severe heart failure, which is accompanied by hypotension and cyanosis, pericardial effusion, low voltage on the electrocardiogram, marked elevation of serum enzymes, and lactic acidosis. They typically have a history of lethargy, anorexia, and weight loss in the months preceding the illness and exhibit other evidence of cobalt’s effects on the body (eg, polycythemia and goiter). The course of cobalt-related cardiomyopathy may be progressive and fatal, but those who survive and cease exposure generally demonstrate complete resolution of symptoms and recovery of cardiac function. Patients presenting with rapid onset of cardiomyopathy, who also exhibit polycythemia, pericardial effusion, or goiter should be evaluated for cobalt exposure. Exposure can be confirmed by the measurement of cobalt in the serum, but serum levels of the ion are not reliably predictive of clinical cardiotoxicity. The clinical emergence of cobalt cardiomyopathy seems to require the coexistence of one or more cofactors, particularly a low-protein diet, thiamine deficiency, alcoholism, and hypothyroidism. As the medicinal use of cobalt has waned and measures to reduce industrial exposure have been implemented, subacute cobalt-related cardiomyopathy had become rare. However, reports describing classical features of the disease have recently surged among patients with a malfunctioning cobalt-alloy hip prosthesis.
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Affiliation(s)
- Milton Packer
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX
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Paukkeri EL, Korhonen R, Hämäläinen M, Pesu M, Eskelinen A, Moilanen T, Moilanen E. The Inflammatory Phenotype in Failed Metal-On-Metal Hip Arthroplasty Correlates with Blood Metal Concentrations. PLoS One 2016; 11:e0155121. [PMID: 27227536 PMCID: PMC4882013 DOI: 10.1371/journal.pone.0155121] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 04/25/2016] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Hip arthroplasty is the standard treatment of a painful hip destruction. The use of modern metal-on-metal (MOM) bearing surfaces gained popularity in total hip arthroplasties during the last decade. Recently, worrisome failures due to adverse reaction to metal debris (ARMD), including pseudotumor response, have been widely reported. However, the pathogenesis of this reaction remains poorly understood. The aim of the present study was to investigate the ARMD response by flow cytometry approach. METHODS Sixteen patients with a failed Articular Surface Replacement (ASR) hip prosthesis were included in the study. Samples of pseudotumor tissues collected during revision surgery were degraded by enzyme digestion and cells were typed by flow cytometry. Whole blood chromium and cobalt concentrations were analyzed with mass spectrometry before revision surgery. RESULTS Flow cytometry analysis showed that the peri-implant pseudotumor tissue expressed two principal phenotypes, namely macrophage-dominated and T-lymphocyte-dominated response; the average portions being 54% (macrophages) and 25% (T-lymphocytes) in macrophage-dominated inflammation and 20% (macrophages) and 54% (T-lymphocytes) in T-lymphocyte-dominated response. The percentages of B-lymphocytes and granulocytes were lower in both phenotypes. Interestingly, the levels of blood chromium and cobalt were significantly higher in patients with macrophage-dominated response. CONCLUSIONS The results suggest that the adverse tissue reactions induced by MOM wear particles contain heterogeneous pathogeneses and that the metal levels are an important factor in the determination of the inflammatory phenotype. The present results support the hypothesis that higher metal levels cause cytotoxicity and tissue injury and macrophages are recruited to clear the necrotic debris. On the other hand, the adverse response developed in association with lower metal levels is T-lymphocyte-dominated and is likely to reflect hypersensitivity reaction.
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Affiliation(s)
- Erja-Leena Paukkeri
- The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Riku Korhonen
- The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Mari Hämäläinen
- The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Marko Pesu
- Immunoregulation, Institute of Biomedical Technology, University of Tampere, Tampere, Finland.,Department of Dermatology, Tampere University Hospital, Tampere, Finland
| | | | - Teemu Moilanen
- The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland.,Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Eeva Moilanen
- The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
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Thomas P, Weik T, Roider G, Summer B, Thomsen M. Influence of Surface Coating on Metal Ion Release: Evaluation in Patients With Metal Allergy. Orthopedics 2016; 39:S24-30. [PMID: 27219723 DOI: 10.3928/01477447-20160509-08] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/03/2016] [Indexed: 02/03/2023]
Abstract
Nickel, chromium, and cobalt in stainless steel and Cobalt-chrome-molybdenum (CoCrMo) alloys may induce allergy. The objectives of this study were to evaluate surface coating regarding ion release, patch test reactivity, and arthroplasty performance. Materials and methods included patch test in 31 patients with metal allergy and 30 patients with no allergy to stainless steel and CoCrMo disks that are uncoated or coated by titanium nitride/zirconium nitride (TiN/ZrN). Assessment include atomic absorption spectrometry of released nickel, cobalt, and chromium from the disks after exposure to distilled water, artificial sweat and culture medium. Results showed that both coatings reduced the nickel and chromium release from stainless steel and CoCrMo disks and mostly the cobalt release from the disks (maximally 11.755 µg/cm(2)/5 d to 1.624 by Ti-N and to 0.442 by ZrN). Six of the 31 patients with metal allergy reacted to uncoated disks, but none reacted to the coated disks. The current authors report on exemplary patients with metal allergy who had symptom relief by revision with surface-coated arthroplasty. The authors concluded that the surface coating may prevent cutaneous and peri-implant allergic reactions. [Orthopedics. 2016; 39(3):S24-S30.].
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Vasconcelos DM, Santos SG, Lamghari M, Barbosa MA. The two faces of metal ions: From implants rejection to tissue repair/regeneration. Biomaterials 2016; 84:262-275. [DOI: 10.1016/j.biomaterials.2016.01.046] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 12/20/2022]
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Malek IA, Rogers J, King AC, Clutton J, Winson D, John A. The Interchangeability of Plasma and Whole Blood Metal Ion Measurement in the Monitoring of Metal on Metal Hips. ARTHRITIS 2015; 2015:216785. [PMID: 26798516 PMCID: PMC4699225 DOI: 10.1155/2015/216785] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/20/2015] [Indexed: 12/12/2022]
Abstract
One hundred and twenty six paired samples of plasma and whole blood were measured with inductively coupled plasma mass spectrometry technique for metal ions analysis to determine a relationship between them. There was a significant difference between the mean plasma and whole blood concentrations of both cobalt (Co) and chromium (Cr) (p < 0.0001 for both Co and Cr). The mean ratio between plasma and whole blood Cr and Co was 1.56 (range: 0.39-3.85) and 1.54 (range: 0.64-18.26), respectively, but Bland and Altman analysis illustrated that this relationship was not universal throughout the range of concentrations. There was higher variability at high concentrations for both ions. We conclude that both these concentrations should not be used interchangeably and conversion factors are unreliable due to concentration dependent variability.
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Affiliation(s)
| | - Joanne Rogers
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK
| | | | - Juliet Clutton
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK
| | - Daniel Winson
- All Wales Orthopaedic Training Programme, Cardiff CF14 4XW, UK
| | - Alun John
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK
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Abstract
BACKGROUND Metal ion release is common following total hip arthroplasty, yet postoperative levels have not been defined for most stems currently used in clinical practice. AIM To assess metal ion release in the serum of patients with well functioning unilateral Exeter V40 primary total hip arthroplasties one year after surgery. METHODS Whole blood chromium and serum cobalt levels were measured in 20 patients following primary total hip arthroplasty with the Exeter V40 stem and a variety of acetabular components one year after surgery. RESULTS Whole blood chromium levels were within the normal range (10-100 nmol/L), with a single mild elevation of serum cobalt (normal <20 nmol/L). CONCLUSIONS In well functioning primary unilateral total hip arthroplasty using the Exeter V40 stem with a variety of acetabular components one year post surgery, whole blood chromium levels are normal and serum cobalt elevations are rare and mild.
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Detection of metal ions in hair after metal–metal hip arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2014. [DOI: 10.1016/j.recote.2014.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Kulichová D, Gehrke T, Kendoff D, Summer B, Parvizi J, Thomas P. Metal Hypersensitivity Mimicking Periprosthetic Erysipelas-Like Infection: A Case Report. JBJS Case Connect 2014; 4:e65. [PMID: 29252586 DOI: 10.2106/jbjs.cc.m.00154] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Daniela Kulichová
- Department of Dermatology and Allergology, Ludwig-Maximilian University, Frauenlobstrasse 9-11, Munich, 80337, Germany.
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, ENDO-Klinik, Holstenstraße 2, Hamburg, 22767, Germany
| | - Daniel Kendoff
- Department of Orthopaedic Surgery, ENDO-Klinik, Holstenstraße 2, Hamburg, 22767, Germany
| | - Burkhard Summer
- Department of Dermatology and Allergology, Ludwig-Maximilian University, Frauenlobstrasse 9-11, Munich, 80337, Germany.
| | - Javad Parvizi
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospitals, 925 Chestnut Street, Philadelphia, PA 19107
| | - Peter Thomas
- Department of Dermatology and Allergology, Ludwig-Maximilian University, Frauenlobstrasse 9-11, Munich, 80337, Germany.
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Gustafson K, Jakobsen SS, Lorenzen ND, Thyssen JP, Johansen JD, Bonefeld CM, Stilling M, Baad-Hansen T, Søballe K. Metal release and metal allergy after total hip replacement with resurfacing versus conventional hybrid prosthesis. Acta Orthop 2014; 85:348-54. [PMID: 24930546 PMCID: PMC4105764 DOI: 10.3109/17453674.2014.922730] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Metal-on-metal (MOM) total hip arthroplasties were reintroduced because of the problems with osteolysis and aseptic loosening related to polyethylene wear of early metal-on-polyethylene (MOP) arthroplasties. The volumetric wear rate has been greatly reduced with MOM arthroplasties; however, because of nano-size wear particles, the absolute number has been greatly increased. Thus, a source of metal ion exposure with the potential to sensitize patients is present. We hypothesized that higher amounts of wear particles result in increased release of metal ions and ultimately lead to an increased incidence of metal allergy. METHODS 52 hips in 52 patients (median age 60 (51-64) years, 30 women) were randomized to either a MOM hip resurfacing system (ReCap) or a standard MOP total hip arthoplasty (Mallory Head/Exeter). Spot urine samples were collected preoperatively, postoperatively, after 3 months, and after 1, 2, and 5 years and tested with inductively coupled plasma-sector field mass spectrometry. After 5 years, hypersensitivity to metals was evaluated by patch testing and lymphocyte transformation assay. In addition, the patients answered a questionnaire about hypersensitivity. RESULTS A statistically significant 10- to 20-fold increase in urinary levels of cobalt and chromium was observed throughout the entire follow-up in the MOM group. The prevalence of metal allergy was similar between groups. INTERPRETATION While we observed significantly increased levels of metal ions in the urine during the entire follow-up period, no difference in prevalence of metal allergy was observed in the MOM group. However, the effect of long-term metal exposure remains uncertain.
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Affiliation(s)
| | | | - Nina D Lorenzen
- Department of Orthopaedic Surgery, Aarhus University Hospital
| | - Jacob P Thyssen
- National Allergy Research Centre, Department of Dermato-allergology, Gentofte University Hospital Copenhagen
| | - Jeanne D Johansen
- National Allergy Research Centre, Department of Dermato-allergology, Gentofte University Hospital Copenhagen
| | - Charlotte M Bonefeld
- Department of International Health, Immunology and Microbiology, University of Copenhagen, Denmark
| | | | | | - Kjeld Søballe
- Department of Orthopaedics, Aarhus University Hospital
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Christian WV, Oliver LD, Paustenbach DJ, Kreider ML, Finley BL. Toxicology-based cancer causation analysis of CoCr-containing hip implants: a quantitative assessment of genotoxicity and tumorigenicity studies. J Appl Toxicol 2014; 34:939-67. [DOI: 10.1002/jat.3039] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/23/2014] [Accepted: 05/24/2014] [Indexed: 12/12/2022]
Affiliation(s)
| | - Lindsay D. Oliver
- Cardno ChemRisk; LLC, 4840 Pearl East Circle, Suite 300 West Boulder CO 80301 USA
| | | | - Marisa L. Kreider
- Cardno ChemRisk, LLC; 20 Stanwix St., Suite 505 Pittsburgh PA 15222 USA
| | - Brent L. Finley
- Cardno ChemRisk; LLC, 231 Front St., Suite 201 Brooklyn NY 11201 USA
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Monnot AD, Christian WV, Paustenbach DJ, Finley BL. Correlation of blood Cr(III) and adverse health effects: Application of PBPK modeling to determine non-toxic blood concentrations. Crit Rev Toxicol 2014; 44:618-37. [DOI: 10.3109/10408444.2014.926472] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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22
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Matusiewicz H. Potential release of in vivo trace metals from metallic medical implants in the human body: from ions to nanoparticles--a systematic analytical review. Acta Biomater 2014; 10:2379-403. [PMID: 24565531 DOI: 10.1016/j.actbio.2014.02.027] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/04/2013] [Accepted: 02/13/2014] [Indexed: 02/06/2023]
Abstract
Metal ion release from metallic materials, e.g. metallic alloys and pure metals, implanted into the human body in dental and orthopedic surgery is becoming a major cause for concern. This review briefly provides an overview of both metallic alloys and pure metals used in implant materials in dental and orthopedic surgery. Additionally, a short section is dedicated to important biomaterials and their corrosive behavior in both real solutions and various types of media that model human biological fluids and tissues. The present review gives an overview of analytical methods, techniques and different approaches applied to the measurement of in vivo trace metals released into body fluids and tissues from patients carrying metal-on-metal prostheses and metal dental implants. Reference levels of ion concentrations in body fluids and tissues that have been determined by a host of studies are compiled, reviewed and presented in this paper. Finally, a collection of published clinical data on in vivo released trace metals from metallic medical implants is included.
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[Detection of metal ions in hair after metal-metal hip arthroplasty]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2014; 58:267-73. [PMID: 24636447 DOI: 10.1016/j.recot.2014.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 01/19/2014] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE There is an increase in the levels of metals in the serum and urine after the implantation of some models of metal-metal hip prosthesis. It has recently been demonstrated that there is an association between these levels and the levels found in hair. The aim of this study is to determine the presence of metals in hair, and to find out whether these change over time or with the removal of the implant. MATERIAL AND METHOD The levels of chromium, cobalt and molybdenum were determined in the hair of 45 patients at 3, 4, 5, and 6 years after a hip surface replacement. The mean age was 57.5 years, and two were female. Further surgery was required to remove the replacement and implant a new model with metal-polyethylene friction in 11 patients, 5 of them due to metallosis and a periarticular cyst. RESULTS The mean levels of metals in hair were chromium 163.27 ppm, cobalt 61.98 ppm, and molybdenum 31.36 ppm, much higher than the levels found in the general population. A decrease in the levels of chromium (43.8%), molybdenum (51.1%), and cobalt (91.1%) was observed at one year in the patients who had further surgery to remove the prosthesis. CONCLUSIONS High concentrations of metals in the hair are observed in hip replacements with metal-metal friction, which decrease when that implant is removed. The determination of metal ions in hair could be a good marker of the metal poisoning that occurs in these arthroplasty models.
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Rodríguez de la Flor M, Hernández-Vaquero D, Fernández-Carreira JM. Metal presence in hair after metal-on-metal resurfacing arthroplasty. J Orthop Res 2013; 31:2025-31. [PMID: 23893786 DOI: 10.1002/jor.22450] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/26/2013] [Indexed: 02/04/2023]
Abstract
The elevation of metal levels in serum and urine during post-operative follow-up is a frequent find following the implantation of certain models of metal-on-metal hip prostheses. Among 45 patients with the same resurfacing prostheses, chromium (Cr) and cobalt (Co) levels in serum and urine were determined at 3, 4, 5, and 6 years after surgery. In the same period, levels of Cr, Co and molibdene (Mo) in scalp hair were also measured. Mean Cr and Co levels in serum were 8.29 µg/L (SD 17.97) and 8.38 µg/L (SD 21.97), respectively, whereas in urine levels were 16.20 µg/L (SD SD 32.55) and 75.40 µg/L (SD 190.86), respectively. In hair, mean Cr level were 163.27 µg/g (SD 300.62), mean Co level 61.98 µg/g (SD 126.48), and Mo 31.36 µg/g (SD 37.86). A high concordance was observed between chromium-urine and chromium-serum and between cobalt-urine and cobalt-hair. A moderate concordance was present between cobalt-urine and cobalt-serum, and between cobalt-hair and cobalt-serum. Eleven patients required revision surgery, five of them due to metallosis and periarticular cyst. At 1 year after reintervention, analytics were performed again and the following decrease rates were found: 42.8% in Cr levels, 51.1% in Mo levels, and 90.3% in Co levels.
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Paustenbach DJ, Galbraith DA, Finley BL. Interpreting cobalt blood concentrations in hip implant patients. Clin Toxicol (Phila) 2013; 52:98-112. [DOI: 10.3109/15563650.2013.857024] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Sansone V, Pagani D, Melato M. The effects on bone cells of metal ions released from orthopaedic implants. A review. ACTA ACUST UNITED AC 2013; 10:34-40. [PMID: 23858309 DOI: 10.11138/ccmbm/2013.10.1.034] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The increasing use of orthopedic implants and, in particular, of hip and knee joint replacements for young and active patients, has stimulated interest and concern regarding the chronic, long-term effects of the materials used. This review focuses on the current knowledge of the adverse biologic reactions to metal particles released from orthopaedic implants in vivo and in vitro. More specifically, the purpose of this article is to provide an overview of the current literature about the adverse effects of metal particles on bone cells and peri-implant bone.
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Affiliation(s)
- Valerio Sansone
- Orthopaedic Department, University of Milan, "Istituto Ortopedico Galeazzi" IRCCS, Milano, Italy
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Wagner P, Olsson H, Ranstam J, Robertsson O, Zheng MH, Lidgren L. Metal-on-metal joint bearings and hematopoetic malignancy. Acta Orthop 2012; 83:553-8. [PMID: 23140092 PMCID: PMC3555450 DOI: 10.3109/17453674.2012.747055] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 09/27/2012] [Indexed: 01/31/2023] Open
Abstract
This is a review of the hip arthroplasty era. We concentrate on new metal bearings, surface replacements, and the lessons not learned, and we highlight recent reports on malignancies and joint implants. A low incidence of blood malignancies has been found in bone marrow taken at prosthetic surgery. The incidence is increased after replacement with knee implants that release very low systemic levels of metal ions. A carcinogenic effect of the high levels of metal ions released by large metal-on-metal implants cannot be excluded. Ongoing Swedish implant registry studies going back to 1975 can serve as a basis for evaluation of this risk.
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Affiliation(s)
- Philippe Wagner
- Departments of Orthopedics, University of Western Australia, Nedlands, Australia
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Meyer H, Mueller T, Goldau G, Chamaon K, Ruetschi M, Lohmann CH. Corrosion at the cone/taper interface leads to failure of large-diameter metal-on-metal total hip arthroplasties. Clin Orthop Relat Res 2012; 470:3101-8. [PMID: 22864616 PMCID: PMC3462871 DOI: 10.1007/s11999-012-2502-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Metal-on-metal (MoM) THAs have reduced wear rates compared with metal-on-polyethylene. However, elevated serum metal ion levels and pseudotumors have been reported in large MoM articulations. QUESTIONS/PURPOSES We therefore determined (1) if corrosion occurred at the cone/taper interface leading to instability in patients with large-diameter THAs; (2) how patients presented clinically and radiographically; (3) if adverse periprosthetic tissue reactions occurred; (4) whether metal was released from the implants into the periprosthetic tissues; and (5) if head size correlated with metal release. METHODS We reviewed 114 patients who had revisions of large-diameter head MoM articulations. Mean time of implantation was 46 months. To identify adverse reactions and particle load, tissues were stained by hematoxylin and eosin and CD3/CD20/CD68 antibodies. Periprosthetic tissues were analyzed for metal content and distribution in different regions. Electrochemical reactions between the stem and adapter were investigated by a minicell electrode. RESULTS Electrochemical studies on the stem and the head adapter showed a risk for galvanic corrosion. Ninety-four percent of patients had instability at the cone/taper interface. All patients presented with early clinical symptoms; 59 patients had radiographic signs of loosening. One hundred four patients had foreign body reactions and necrosis. The largest amounts of metal released were titanium or iron. We found no correlation between head size and metal ion release. CONCLUSIONS These findings suggest that in modular cone/taper connections, friction of the MoM articulations may cause failure of the cone/taper interface leading to galvanic corrosion and loosening. It is unclear whether the design of this MoM system provides sufficient stability at the taper.
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Affiliation(s)
- Heiko Meyer
- Department of Orthopaedics, Otto-von-Guericke University, Leipziger Str 44, 39108 Magdeburg, Germany
| | - Tina Mueller
- Department of Orthopaedics, Otto-von-Guericke University, Leipziger Str 44, 39108 Magdeburg, Germany
| | - Gesine Goldau
- University of Applied Sciences, Magdeburg-Stendal, Germany
| | - Kathrin Chamaon
- Department of Orthopaedics, Otto-von-Guericke University, Leipziger Str 44, 39108 Magdeburg, Germany
| | - Marcel Ruetschi
- Department of Orthopaedics, Loretto Hospital, Freiburg, Germany
| | - Christoph H. Lohmann
- Department of Orthopaedics, Otto-von-Guericke University, Leipziger Str 44, 39108 Magdeburg, Germany
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Granchi D, Cenni E, Giunti A, Baldini N. Metal hypersensitivity testing in patients undergoing joint replacement: a systematic review. ACTA ACUST UNITED AC 2012; 94:1126-34. [PMID: 22844057 DOI: 10.1302/0301-620x.94b8.28135] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
We report a systematic review and meta-analysis of the peer-reviewed literature focusing on metal sensitivity testing in patients undergoing total joint replacement (TJR). Our purpose was to assess the risk of developing metal hypersensitivity post-operatively and its relationship with outcome and to investigate the advantages of performing hypersensitivity testing. We undertook a comprehensive search of the citations quoted in PubMed and EMBASE: 22 articles (comprising 3634 patients) met the inclusion criteria. The frequency of positive tests increased after TJR, especially in patients with implant failure or a metal-on-metal coupling. The probability of developing a metal allergy was higher post-operatively (odds ratio (OR) 1.52 (95% confidence interval (CI) 1.06 to 2.31)), and the risk was further increased when failed implants were compared with stable TJRs (OR 2.76 (95% CI 1.14 to 6.70)). Hypersensitivity testing was not able to discriminate between stable and failed TJRs, as its predictive value was not statistically proven. However, it is generally thought that hypersensitivity testing should be performed in patients with a history of metal allergy and in failed TJRs, especially with metal-on-metal implants and when the cause of the loosening is doubtful.
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Affiliation(s)
- D Granchi
- Rizzoli Orthopaedic Institute, Laboratory for Orthopaedic Pathophysiology and Regenerative Medicine, Via di Barbiano 1/10, 40136 Bologna, Italy.
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Fritzsche J, Borisch C, Schaefer C. Case report: High chromium and cobalt levels in a pregnant patient with bilateral metal-on-metal hip arthroplasties. Clin Orthop Relat Res 2012; 470:2325-31. [PMID: 22692823 PMCID: PMC3392404 DOI: 10.1007/s11999-012-2398-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 05/10/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Metal-on-metal bearings frequently are used in young patients leading to the concern that disseminated metals such as chromium (Cr) and cobalt (Co) as the main constituents could affect pregnancies. CASE DESCRIPTION We describe a 41-year-old patient with bilateral metal-on-metal hip arthroplasties, a recurrent pseudotumor, and extremely high blood levels (Cr 39 μg/L, Co 138 μg/L) at 12 gestational weeks. At different gestational weeks, maternal blood, aspirate of the pseudotumor, and amniotic fluid were analyzed for Cr and Co. Therapy with chelating agents was not recommended because the mother showed no symptoms of toxicity and the safety of chelating therapy during pregnancy is not established. At 38 weeks of gestation, a healthy male infant was delivered with elevated Cr and Co cord blood levels. At the age of 8 weeks, the infant's Cr was comparable to the cord blood level, whereas the Co decreased considerably without treatment. At the age of 14 weeks, the infant's development was seemingly uneventful and no signs of toxicity were obvious. LITERATURE REVIEW Carcinogenic, mutagenic, and teratogenic potentials of these metals have been suggested. However, we found no published clinical observations in context with pregnancies of women with hip arthroplasties using metal-on-metal implants. To our knowledge, this is the first report of such high levels of Cr and Co in a human pregnancy. PURPOSES AND CLINICAL RELEVANCE Although we cannot generalize from one case, the seemingly uneventful outcome of this pregnancy may reassure colleagues when counseling patients with high ion levels whether to carry a pregnancy to term.
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Affiliation(s)
- Juliane Fritzsche
- Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie (Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy), Institut für Klinische Pharmakologie und Toxikologie, Charité Universitätsmedizin Berlin, Spandauer Damm 130, Haus 10, D-14050 Berlin, Germany
| | - Cornelia Borisch
- Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie (Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy), Institut für Klinische Pharmakologie und Toxikologie, Charité Universitätsmedizin Berlin, Spandauer Damm 130, Haus 10, D-14050 Berlin, Germany
| | - Christof Schaefer
- Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie (Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy), Institut für Klinische Pharmakologie und Toxikologie, Charité Universitätsmedizin Berlin, Spandauer Damm 130, Haus 10, D-14050 Berlin, Germany
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Malek IA, King A, Sharma H, Malek S, Lyons K, Jones S, John A. The sensitivity, specificity and predictive values of raised plasma metal ion levels in the diagnosis of adverse reaction to metal debris in symptomatic patients with a metal-on-metal arthroplasty of the hip. ACTA ACUST UNITED AC 2012; 94:1045-50. [DOI: 10.1302/0301-620x.94b8.27626] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Plasma levels of cobalt and chromium ions and Metal Artefact Reduction Sequence (MARS)-MRI scans were performed on patients with 209 consecutive, unilateral, symptomatic metal-on-metal (MoM) hip arthroplasties. There was wide variation in plasma cobalt and chromium levels, and MARS-MRI scans were positive for adverse reaction to metal debris (ARMD) in 84 hips (40%). There was a significant difference in the median plasma cobalt and chromium levels between those with positive and negative MARS-MRI scans (p < 0.001). Compared with MARS-MRI as the potential reference standard for the diagnosis of ARMD, the sensitivity of metal ion analysis for cobalt or chromium with a cut-off of > 7 µg/l was 57%. The specificity was 65%, positive predictive value was 52% and the negative predictive value was 69% in symptomatic patients. A lowered threshold of > 3.5 µg/l for cobalt and chromium ion levels improved the sensitivity and negative predictive value to 86% and 74% but at the expense of specificity (27%) and positive predictive value (44%). Metal ion analysis is not recommended as a sole indirect screening test in the surveillance of symptomatic patients with a MoM arthroplasty. The investigating clinicians should have a low threshold for obtaining cross-sectional imaging in these patients, even in the presence of low plasma metal ion levels.
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Affiliation(s)
- I. A. Malek
- Wales Deanery, Neuadd
Meirionnydd, Heath Park, Cardiff, CF14
4YS, UK
| | - A. King
- University Hospital of Wales, Heath
Park, Cardiff CF14 4XW, UK
| | - H. Sharma
- University Hospital of Wales, Heath
Park, Cardiff CF14 4XW, UK
| | - S. Malek
- St. Helens and Knowsley Teaching Hospitals
NHS Trust, Marshalls Cross Road, St Helens
WA9 3DA, UK
| | - K. Lyons
- University Hospital of Wales, Heath
Park, Cardiff CF14 4XW, UK
| | - S. Jones
- University Hospital of Wales, Heath
Park, Cardiff CF14 4XW, UK
| | - A. John
- University Hospital of Wales, Heath
Park, Cardiff CF14 4XW, UK
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Polyzois I, Nikolopoulos D, Michos I, Patsouris E, Theocharis S. Local and systemic toxicity of nanoscale debris particles in total hip arthroplasty. J Appl Toxicol 2012; 32:255-69. [PMID: 22328167 DOI: 10.1002/jat.2729] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 12/29/2011] [Accepted: 12/29/2011] [Indexed: 11/06/2022]
Abstract
Over the past 30 years joint replacement prostheses have been developed and refined to enhance durability and reproducibility. Total hip joint arthroplasty is being performed in an increasing number of younger patients; therefore orthopaedic surgeons seek implants with a longer life span. With regards to the progress of mechanical behaviour of the biomaterials used in an arthroplasty, little is known about the long-term biological effects of wear debris. Owing to the composition of the prostheses currently in use, systemic exposure to chromium (Cr), cobalt (Co), nickel (Ni) and aluminium (Al) alloys occurs as a result of the formation of metal wear nano-particles that are released both from metal-on-metal and polyethylene-on-metal bearings, resulting in a postoperative increase in metal ion levels at different organ sites. These particles circulate both locally and systemically, penetrate cell plasma membranes, bind to cellular proteins and enzymes and modulate cytokine expression. Their physiologic effects are poorly understood and their potential toxicity, hypersensitivity and carcinogenicity remain a cause for concern. In this article we will address the issue of whether these nanoscale degradation products are associated with adverse, clinically significant local or systemic toxicologic sequelae.
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Affiliation(s)
- Ioannis Polyzois
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, and 4th Orthopaedic Department, Ascleipion Voulas General Hospital, Athens, Greece
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Finley BL, Monnot AD, Gaffney SH, Paustenbach DJ. Dose-response relationships for blood cobalt concentrations and health effects: a review of the literature and application of a biokinetic model. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART B, CRITICAL REVIEWS 2012; 15:493-523. [PMID: 23199219 DOI: 10.1080/10937404.2012.744287] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Cobalt (Co) is an essential component of vitamin B(12). As with all metals, at sufficiently high doses, Co may exert detrimental effects on different organ systems, and adverse responses have been observed in animals, patients undergoing Co therapy, and workers exposed to respirable Co particulates. Although blood Co concentrations are postulated to be the most accurate indicator of ongoing Co exposure, little is known regarding the dose-response relationships between blood Co concentrations and adverse health effects in various organ systems. In this analysis, the animal toxicology and epidemiology literature were evaluated to identify blood Co concentrations at which effects have, and have not, been reported. Where necessary, a biokinetic model was used to convert oral doses to blood Co concentrations. Our results indicated that blood Co concentrations of 300 μg/L and less have not been associated with adverse responses of any type in humans. Concentrations of 300 μg/L and higher were associated with certain hematological and reversible endocrine responses, including polycythemia and reduced iodide uptake. Blood Co concentrations of 700-800 μg Co/L and higher may pose a risk of more serious neurological, reproductive, or cardiac effects. These blood concentrations should be useful to clinicians and toxicologists who are attempting to interpret blood Co concentrations in exposed individuals.
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Abstract
In joint reconstruction, the techniques and materials that provide the best outcomes for patients have been debated. The main points of controversy relate to the use of hemiarthroplasties versus total joint prostheses with metal-on-metal versus metal-on-polyethylene articulations. This article investigates these areas as well as the applicability of the techniques and materials and the complications that can occur. Hypersensitivity to materials used in joint prostheses is relatively common but often unrecognized. Although the discussion applies to all joints, the temporomandibular joint (TMJ) is emphasized. For TMJ reconstruction, metal-on-polyethylene articulation in total joint prostheses provides better treatment outcomes than metal-on-metal articulation.
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Affiliation(s)
- Larry M Wolford
- Department of Oral and Maxillofacial Surgery, Baylor University Medical Center, and Baylor College of Dentistry, Texas A&M University System, Dallas, Texas, USA.
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Pazzaglia UE, Apostoli P, Congiu T, Catalani S, Marchese M, Zarattini G. Cobalt, chromium and molybdenum ions kinetics in the human body: data gained from a total hip replacement with massive third body wear of the head and neuropathy by cobalt intoxication. Arch Orthop Trauma Surg 2011; 131:1299-308. [PMID: 21298277 DOI: 10.1007/s00402-011-1268-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Indexed: 11/29/2022]
Abstract
INTRODUCTION A patient with a total hip replacement developed optic, acoustic and peripheral neuropathy from metal ions intoxication, due to the wear products released from the prosthesis. Subsequently the kinetics of the metal ions was studied. MATERIALS AND METHODS Massive wear and acute intoxication allowed a study of the metal ions kinetics and of EDTA treatment. RESULTS Plasma and other organic fluids were saturated by each of the metal ions released from the exposed surface according to the solubility of each ion; a larger fraction of Co ions was bound within red cells, while the plasmatic fraction appeared more movable. In a patient with a prosthesis subjected to wear, the ions released are from the prosthetic and from the debris surface (spread in the body). The latter is a function of the number and size of particles. DISCUSSION Revision of the prosthesis from the point of view of the metal ions kinetics corresponded to a reduction of the releasing surface because of debris washed out by irrigation and tissue excision; however, the metal particles spread by lymphatic circulation continued to release ions even though the source of wear had been removed. Early diagnosis of high metal wear can be ascertained with mass spectrometry and after revision high levels of metal ions can only be reduced with repeated chelating treatment. It is preferable not to revise fractured ceramic components with a polyethylene-metal articulation.
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Haddad FS, Thakrar RR, Hart AJ, Skinner JA, Nargol AVF, Nolan JF, Gill HS, Murray DW, Blom AW, Case CP. Metal-on-metal bearings: the evidence so far. ACTA ACUST UNITED AC 2011; 93:572-9. [PMID: 21511920 DOI: 10.1302/0301-620x.93b4.26429] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Lately, concerns have arisen following the use of large metal-on-metal bearings in hip replacements owing to reports of catastrophic soft-tissue reactions resulting in implant failure and associated complications. This review examines the literature and contemporary presentations on current clinical dilemmas in metal-on-metal hip replacement.
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Affiliation(s)
- F S Haddad
- Department of Orthopaedics, University College Hospital, 235 Euston Road, London NW1 2BU, UK.
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Thyssen JP, Roeske-Nielsen A, Johansen JD. Contact allergy and human biomonitoring--an overview with a focus on metals. Contact Dermatitis 2011; 65:125-37. [PMID: 21692808 DOI: 10.1111/j.1600-0536.2011.01933.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Humans are widely exposed to chemicals. Today, there is an increased acknowledgement of the importance of measuring human and environmental exposures to man-made or refined chemicals. Different approaches have been applied over time, but during the past 25 years, there has been a general trend towards the use of human biomonitoring. A few studies have used human biomonitoring methodology to track contact allergens together with information on patch test reactivity. Hypothetically, the internal load of reactive chemicals might modify the immune response to haptens and the propensity to sensitize and elicit allergic contact dermatitis or develop tolerance. This review offers a general overview of human biomonitoring, including information about its typical application and methodology. Furthermore, studies that have attempted to perform simultaneous biomonitoring and patch testing are reviewed. It is concluded that all studies conducted until the present have focused on one or two routes of exposure (typically skin and oral exposure, but also skin and airway exposure), whereas no studies have investigated all routes at the same time. Also, there is a need for prospective studies, as all epidemiological studies so far have been cross-sectional.
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Affiliation(s)
- Jacob P Thyssen
- Department of Dermato-Allergology, National Allergy Research Centre, Copenhagen University Hospital Gentofte, University of Copenhagen, DK-2900 Hellerup, Denmark.
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Devitt BM, Queally JM, Vioreanu M, Butler JS, Murray D, Doran PP, O'Byrne JM. Cobalt ions induce chemokine secretion in a variety of systemic cell lines. Acta Orthop 2010; 81:756-64. [PMID: 21110705 PMCID: PMC3216089 DOI: 10.3109/17453674.2010.537806] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Metal ion toxicity both locally and systemically following MoM hip replacements remains a concern. Cobalt ions have been shown to induce secretion of proinflammatory chemokines locally; however, little is known about their effect systemically. We investigated the in vitro effect of cobalt ions on a variety of cell lines by measuring production of the proinflammatory chemokines IL-8 and MCP-1. METHOD Renal, gastrointestinal, and respiratory epithelium and also neutrophils and monocytes were exposed to cobalt ions at 4, 12, 24, and 48 hours. RESULTS We found that cobalt ions enhanced the secretion of IL-8 and MCP-1 in renal epithelial cells, gastric and colon epithelium, monocytes and neutrophils, and small airway epithelial cells but not in alveolar cells. Secretion of IL-8 and MCP-1 was markedly elevated in renal epithelium, where a 16-fold and 7-fold increase occurred compared to controls. There was a 6-fold and 4-fold increase in IL-8 and MCP-1 secretion in colon epithelium and a 4-fold and 3-fold increase in gastric epithelium. Small airway epithelial cells showed a maximum increase in secretion of 8-fold (IL-8) and of 4-fold (MCP-1). The increase in chemokine secretion observed in alveolar cells was moderate and did not reach statistical significance. Monocytes and neutrophils showed a 2.5-fold and 2-fold increase in IL-8 secretion and a 6-fold and 4-fold increase in MCP-1 secretion at 48 and 24 hours, respectively. INTERPRETATION These data demonstrate the potent bioactivity of cobalt ions in a variety of cell types and the potential to induce a proinflammatory response.
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Affiliation(s)
- Brian M Devitt
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - Joseph M Queally
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - Mihai Vioreanu
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - Joseph S Butler
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - David Murray
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - Peter P Doran
- UCD Clinical Research Centre, UCD School of Medicine and Medical Sciences, Mater Misericordiæ University Hospital
| | - John M O'Byrne
- Department of Trauma and Orthopaedic Surgery, Royal College of Surgeons in Ireland, Cappagh National Orthopaedic Hospital, Dublin, Ireland
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Liu FC, Qin J, Wu HS, Wu YL, Zhu YL. Co and Cr accumulation in hair after metal-on-metal hip resurfacing arthroplasty. ANZ J Surg 2010; 81:436-9. [DOI: 10.1111/j.1445-2197.2010.05576.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Catalani S, Leone R, Rizzetti MC, Padovani A, Apostoli P. The role of albumin in human toxicology of cobalt: contribution from a clinical case. ISRN HEMATOLOGY 2010; 2011:690620. [PMID: 22084701 PMCID: PMC3198613 DOI: 10.5402/2011/690620] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 10/21/2010] [Indexed: 11/23/2022]
Abstract
The distribution and adverse effects, especially to optic and acoustic nerves, of cobalt released from a hip arthroplasty and its association with albumin were studied. The analysis of cobalt was performed in plasma, whole blood, urine, and cerebrospinal fluid by inductively coupled plasma mass spectrometry (ICP-MS). The fraction of albumin binding the metal was determined by colorimetric assay using dithiothreitol (DTT). In all the biological matrices very high levels of cobalt were measured, but contrary to expected, a higher concentration in whole blood than in plasma was observed. The determination of altered albumin confirmed this hypothesis. This evidence might indicate an alteration in the binding of cobalt to albumin and a consequent increase in the concentration of the diffusible (free) fraction of the metal. This appears an interesting starting point for further investigations for identifying and better understanding cobalt neurotoxicity, apparently not so frequent in occupational medicine and clinical practice.
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Affiliation(s)
- Simona Catalani
- Section of Occupational Health and Industrial Hygiene, Department of Experimental and Applied Medicine, University of Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy
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Romesburg JW, Wasserman PL, Schoppe CH. Metallosis and Metal-Induced Synovitis Following Total Knee Arthroplasty: Review of Radiographic and CT Findings. J Radiol Case Rep 2010; 4:7-17. [PMID: 22470753 DOI: 10.3941/jrcr.v4i9.423] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Metallosis and metal-induced synovitis are well-recognized complications of metal-backed polyethylene joint prostheses and have been frequently described in the orthopedic surgery literature; however, relatively fewer articles discussing the radiologic aspects of this complication have been published. To illustrate the importance of radiologic findings in the diagnosis and management of these patients, we present a case of metallosis and metal-induced synovitis complicating two revisions of a total knee arthroplasty, caused by polyethylene liner wear and dissociation of the polyethylene liner from the metal-backed patellar prosthesis. Specific attention is given to reviewing signs that aid in diagnosis, such as the "bubble sign," "cloud sign," and "metal-line signs."
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Affiliation(s)
- Jason W Romesburg
- Department of Radiology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA
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43
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Summer B, Paul C, Mazoochian F, Rau C, Thomsen M, Banke I, Gollwitzer H, Dietrich KA, Mayer-Wagner S, Ruzicka T, Thomas P. Nickel (Ni) allergic patients with complications to Ni containing joint replacement show preferential IL-17 type reactivity to Ni. Contact Dermatitis 2010; 63:15-22. [DOI: 10.1111/j.1600-0536.2010.01744.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Visuri T, Borg H, Pulkkinen P, Paavolainen P, Pukkala E. A retrospective comparative study of mortality and causes of death among patients with metal-on-metal and metal-on-polyethylene total hip prostheses in primary osteoarthritis after a long-term follow-up. BMC Musculoskelet Disord 2010; 11:78. [PMID: 20416065 PMCID: PMC2874765 DOI: 10.1186/1471-2474-11-78] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Accepted: 04/23/2010] [Indexed: 11/13/2022] Open
Abstract
Background All patients with total hip arthroplasty (THA), especially those with metal-on-metal (MM) THA, are exposed to metallic particles and ions, which may cause total or site-specific mortality. We analyzed the causes of total and site-specific mortality among a cohort of patients with MM and with metal-on-polyethylene (MP) THA after a long follow-up time. Methods Standardized mortality ratios (SMR) of total and site-specific causes of death were calculated for 579 patients with MM (McKee-Farrar) and 1585 patients with MP (Brunswik, Lubinus) THA for primary osteoarthritis. Results Mean follow-up time was 17.9 years for patients with MM and 16.7 years for patients with MP. Overall SMR was 0.95 for the MM cohort and 0.90 for the MP cohort, as compared to the normal population. Both cohorts showed significantly decreased mortality for the first decade postoperatively, equal mortality over the next 10 years, and significantly increased mortality after 20 years. Patients with MM THA had higher cancer mortality (SMR 1.01) than those with MP THA (SMR 0.66) during the first 20 years postoperatively, but not thereafter. Conclusion Both MM and MP prostheses are safe based on total and site-specific mortality of recipients during the first 20 postoperative years in comparison with the general population.
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Affiliation(s)
- Tuomo Visuri
- Research Institute of Military Medicine, Helsinki, Finland.
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47
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Thyssen J, Johansen J, Menné T, Lidén C, Bruze M, White I. Hypersensitivity reactions from metallic implants: a future challenge that needs to be addressed. Br J Dermatol 2010; 162:235-6. [DOI: 10.1111/j.1365-2133.2009.09526.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Thyssen JP, Jakobsen SS, Engkilde K, Johansen JD, Søballe K, Menné T. The association between metal allergy, total hip arthroplasty, and revision. Acta Orthop 2009; 80:646-52. [PMID: 19995314 PMCID: PMC2823320 DOI: 10.3109/17453670903487008] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE It has been speculated that the prevalence of metal allergy may be higher in patients with implant failure. We compared the prevalence and cause of revisions following total hip arthroplasty (THA) in dermatitis patients suspected to have contact allergy and in patients in general with THA. Furthermore, we compared the prevalence of metal allergy in dermatitis patients with and without THA. MATERIALS AND METHODS The Danish Hip Arthroplasty Registry (DHAR) contained detailed information on 90,697 operations. The Gentofte patch-test database contained test results for patients suspected of having allergic contact dermatitis (n = 18,794). Cases (n = 356) were defined as patch-tested dermatitis patients who also had primary THA performed. Two age- and sex-matched controls (n = 712) from the patch-test database were sought for each case. RESULTS The prevalence of revision was similar in cases (12%) and in patients from the DHAR (13%). The prevalence of metal allergy was similar in cases and controls. However, the prevalence of metal allergy was lower in cases who were patch-tested after operation (6%) than in those who were patch-tested before operation (16%) (OR = 2.9; 95% CI = 1-8). INTERPRETATION We found that the risk of surgical revision was not increased in patients with metal allergies and that the risk of metal allergy was not increased in cases who were operated, in comparison to controls. Despite some important study limitations, our observations add to the evidence that the risk of complications in metal allergic patients seems limited.
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Affiliation(s)
- Jacob Pontoppidan Thyssen
- National Allergy Research Centre, Department of Dermato-allergology, Gentofte Hospital, University of Copenhagen, Copenhagen
| | | | - Kåre Engkilde
- National Allergy Research Centre, Department of Dermato-allergology, Gentofte Hospital, University of Copenhagen, Copenhagen
| | - Jeanne Duus Johansen
- National Allergy Research Centre, Department of Dermato-allergology, Gentofte Hospital, University of Copenhagen, Copenhagen
| | - Kjeld Søballe
- Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
| | - Torkil Menné
- National Allergy Research Centre, Department of Dermato-allergology, Gentofte Hospital, University of Copenhagen, Copenhagen
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Cadosch D, Chan E, Gautschi OP, Filgueira L. Metal is not inert: Role of metal ions released by biocorrosion in aseptic loosening-Current concepts. J Biomed Mater Res A 2009; 91:1252-62. [DOI: 10.1002/jbm.a.32625] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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50
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A study of the exposure of various population groups to platinum in Vienna (Austria) through urine analysis by inductively coupled plasma-mass spectrometry. Microchem J 2009. [DOI: 10.1016/j.microc.2009.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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