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Bogdonoff YM, Amirouche F. Addressing metallosis in knee arthroplasty: From diagnostic challenges to innovative treatments. World J Orthop 2024; 15:386-389. [PMID: 38835685 PMCID: PMC11145969 DOI: 10.5312/wjo.v15.i5.386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/14/2024] [Accepted: 04/11/2024] [Indexed: 05/15/2024] Open
Abstract
In this editorial, we comment on the article by Toro et al published in the recent issue of World Journal of Orthopedics. This editorial review provides a comprehensive exploration of the landscape surrounding knee arthroplasty metallosis, focusing on key aspects ranging from the mechanisms influencing susceptibility to clinical implications and advanced treatment strategies. We elucidate the complex interplay of implant design, patient-specific variables, and wear-related processes contributing to metallosis. Furthermore, we seek to shed light on diagnostic challenges, the necessity of a multidisciplinary approach, and the imperative for vigilant implant surveillance. Uni-on-uni revision, as a targeted treatment modality, is discussed, highlighting its potential to address metallosis in unicompartmental knee arthroplasty (UKA). There is a need for heightened awareness among clinicians regarding the subtle presentations of metallosis, coupled with the limitations of traditional imaging techniques. Addressing metallosis requires a collaborative, multidisciplinary approach to effectively navigate the complexities associated with this complication. Furthermore, the review emphasizes the evolving paradigm of personalized care, with uni-on-uni revision emerging as a promising surgical solution. In conclusion, the editorial outlines the dynamic nature of knee arthroplasty metallosis and its multifaceted impact on clinical practice. It calls for ongoing collaboration, education, and integration of innovative solutions to enhance diagnostic accuracy, proactive management, and overall patient outcomes in the realm of UKA.
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Affiliation(s)
- Yvon Maurice Bogdonoff
- Department of Orthopedics Surgery, University of Illinois at Chicago, Chicago, IL 60612, United States
| | - Farid Amirouche
- Department of Orthopedics Surgery, University of Illinois at Chicago, Chicago, IL 60612, United States
- Department of Orthopedics Surgery, Northshore University Health System, Skokie, IL 60076, United States
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Holland CT, Shenoy A, Lachiewicz PF. Failure of a Femoral Revision Knee Component with Chemical Corrosion and Elevated Metal Ions: A Case Report and Literature Review. JBJS Case Connect 2023; 13:01709767-202309000-00006. [PMID: 37437076 DOI: 10.2106/jbjs.cc.23.00043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
CASE Failure of the modular junction in revision total knee arthroplasty is a rare complication. We report a patient with late, atraumatic failure of a modern, modular revision femoral component, with preoperative elevation of serum cobalt and chromium levels. Retrieval analysis showed extensive chemical corrosion. CONCLUSION Failure of a modern, modular femoral component may cause metal synovitis and elevated serum metal levels. Subtle radiographic changes and preoperative serum metal levels may identify this complication.
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Affiliation(s)
- Christopher T Holland
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Aarti Shenoy
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Paul F Lachiewicz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Koyama T, Mori Y, Kamimura M, Aki T, Izumiyama T, Mori N, Chiba D, Hashimoto K, Yamamoto N, Aizawa T. Two-stage revision knee arthroplasty for metallosis in a patient with rheumatoid arthritis: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231177752. [PMID: 37325170 PMCID: PMC10265328 DOI: 10.1177/2050313x231177752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/08/2023] [Indexed: 06/17/2023] Open
Abstract
We report a successful case of two-stage revision total knee arthroplasty performed for treating painless metallosis after total knee arthroplasty with a metal-backed patella. A 63-year-old woman diagnosed with rheumatoid arthritis underwent left total knee arthroplasty with a metal-backed patella at 32 years of age. The patient did not have knee pain; however, knee joint swelling, a strange noise, and pigmentation were reported 4 years ago. Radiographs showed cloud and metal-line signs anteriorly and posteriorly at the femoral condyle. Therefore, a two-stage surgery was performed for infection prevention and ease of performing posterior synovectomy. The patient underwent initial synovectomy via a posterior approach, followed by anterior synovectomy and revision total knee arthroplasty. Synovectomy was performed well without perioperative infection or failure of wound healing. In cases with metallosis after total knee arthroplasty, the two-stage revision total knee arthroplasty should be considered, depending on the degree of synovial proliferation and the risk of complications.
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Affiliation(s)
- Tomoki Koyama
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Mori
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masayuki Kamimura
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Aki
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takuya Izumiyama
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Naoko Mori
- Department of Radiology, Akita University Graduate School of Medicine, Akita, Japan
| | - Daisuke Chiba
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Nobuyuki Yamamoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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4
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Liepe K. Radiosynovectomy of large joint arthritis. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00024-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Bettiol P, Egan A, Cox C, Wait E, Brindley G. Pathological analysis of periprosthetic soft tissue and modes of failure in revision total joint arthroplasty patients. SAGE Open Med 2021; 9:20503121211047099. [PMID: 34589221 PMCID: PMC8474343 DOI: 10.1177/20503121211047099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/31/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives Implant failure leading to revision total joint arthroplasty can occur through a variety of different mechanisms which are typically associated with a soft tissue response adjacent to the implant that provide insight into the underlying etiology of implant failure. The objective of this study was to elucidate mechanisms of implant failure as they relate to histological classification and findings of adjacent periprosthetic tissue. Methods Histological analysis of soft tissue adjacent to the implant was performed in 99 patients with an average age of 64 years old and grouped into four categories based on the study conducted by Morawietz et al.:Type I (N = 47)Wear particle induced typeType II (N = 7)Infectious typeType III (N = 19)Combined type I and IIType IV (N = 26)Indeterminant typeModes of failure were categorized into five groupings based on the study conducted by Callies et al.: Instability (N = 35), Aseptic Loosening (N = 24), Hardware and/or Mechanical Failure (N = 15), Septic (N = 13), and Other failures (N = 12). We calculated odds ratios and conducted regression analysis to assess the relationship between modes of failure and histological findings as well as modes of failure and comorbidities. Results Hardware/mechanical failure was independently correlated with histological findings of anucleate protein debris, histiocytes, Staphylococcus epidermidis, and synovitis. Furthermore, hardware/mechanical failure was independently correlated with osteosarcoma as a co-morbidity. Septic failure was associated with histological findings of Enterococcus, granulation tissue, and tissue necrosis as well as comorbidities of Crohn's disease, deep venous thrombosis, lung disease, and rheumatoid arthritis. Infection was 5.8 times more likely to be associated with Type II histology. Aseptic loosening was associated with histologic findings of synovitis. Conclusion Our findings support the existing literature on periprosthetic tissue analysis in revision total joint arthroplasty which may improve surgeon understanding of the patholophysiological mechanisms that contribute to implant failure and revision surgery.
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Affiliation(s)
- Patrick Bettiol
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Alec Egan
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Cameron Cox
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Eric Wait
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - George Brindley
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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6
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Crawford DA, Passias BJ, Adams JB, Berend KR, Lombardi AV. Impact of perivascular lymphocytic infiltration in aseptic total knee revision. Bone Joint J 2021; 103-B:145-149. [PMID: 34053288 DOI: 10.1302/0301-620x.103b6.bjj-2020-2051.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS A limited number of investigations with conflicting results have described perivascular lymphocytic infiltration (PVLI) in the setting of total knee arthroplasty (TKA). The purpose of this study was to determine if PVLI found in TKAs at the time of aseptic revision surgery was associated with worse clinical outcomes and survivorship. METHODS A retrospective review was conducted on 617 patients who underwent aseptic TKA revision who had histological analysis for PVLI at the time of surgery. Clinical and radiological data were obtained pre- and postoperatively, six weeks postoperatively, and then every year thereafter. RESULTS Within this cohort, 118 patients (19.1%) were found to have PVLI on histological analysis. Re-revision was performed on 83 patients (13.4%) with no significant differences in all-cause or aseptic revisions between groups. A higher incidence of PVLI was noted in female patients (p = 0.037). There was no significant difference in improvement in the range of motion (p = 0.536), or improvement of KSC (p = 0.66), KSP (p = 0.61), or KSF (p = 0.3) clinical outcome scores between PVLI and no PVLI sub-groups. There was a higher incidence of a preoperative diagnosis of pain in the PVLI group compared with patients without PVLI (p = 0.002) present. CONCLUSION PVLI found on large-scale histological analysis in TKAs at aseptic revision surgery was not associated with worse clinical outcomes or rates of re-revision. Cite this article: Bone Joint J 2021;103-B(6 Supple A):145-149.
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Affiliation(s)
| | | | | | - Keith R Berend
- Joint Implant Surgeons, Inc, New Albany, Ohio, USA.,Mount Carmel Health System, New Albany, Ohio, USA
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc, New Albany, Ohio, USA.,Mount Carmel Health System, New Albany, Ohio, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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7
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Liepe K, Baehr M. 90Y Radiosynovectomy in Persistent Synovitis Caused by Knee Replacement: Long-Term Outcome. Clin Nucl Med 2021; 46:21-24. [PMID: 33234919 DOI: 10.1097/rlu.0000000000003405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION After knee replacement, therapy resistant, persistent synovitis is a common issue, which causes effusion and pain, and leads to loosing. It has been hypothesized that radiosynovectomy (RSO) is useful in these patients. MATERIALS AND METHODS A cohort of 55 patients with 57 knee replacements and persistent synovitis underwent RSO using 4.9 ± 0.24 mCi (182 ± 9 MBq) of Y-citrate. The number of RSOs ranged from 1 to 4. Bone scans before and 3 months after every RSO were performed. Long-term follow-up ranged from 0.8 to 7.6 years with a mean of 23.2 months. For qualitative analysis, an established 4 steps scoring was used. For quantification, the uptake was determined within the Tc-MDP scintigraphy blood pool phase before and after therapy. RESULTS Long-term response was in 27% with excellent, 24% good, 30% weak, and 20% no response. The duration of response was 12.0 ± 12.0 months (maximum, 54 months). In patients with repeated treatment, the effect after the first therapy was lesser than in patients who received a single treatment in total. However, 3 months after the last RSO, patients with repeated treatment showed a similar effectiveness than single treated patients. At the end of long-term follow-up, patients with repeated RSOs had a higher effectiveness at similar duration response. In bone scan, 65% of patients showed a reduction of uptake. When comparing subjective and objective response, 78% of patients showed a concordance in both symptoms and scintigraphy. Pilot histological analysis revealed that the synovitis is triggered by small plastic particles. CONCLUSIONS We concluded that RSO is an effective therapy in patients with knee replacement and persistent synovitis with high long-term response. Repeated treatment leads to a stronger long-time response.
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Affiliation(s)
- Knut Liepe
- From the Department of Nuclear Medicine, GH Hospital Frankfurt (Oder), Frankfurt (Oder), Germany
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8
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Purcell A, Buckner S, Brindley G, Grimes J. A Unique Case of Extra-articular Extravasation of Metal Into the Lower Leg Resulting From Oxidized Zirconium Wear Particles From Total Knee Arthroplasty. Arthroplast Today 2020; 6:988-992. [PMID: 33385039 PMCID: PMC7772447 DOI: 10.1016/j.artd.2020.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/13/2020] [Accepted: 09/20/2020] [Indexed: 01/07/2023] Open
Abstract
With an increasing number of joint replacements and the evolution of orthopaedic implants and hardware, there is increased occurrence and awareness of metal-related sensitivity. This has resulted in the development of devices using a variety of different materials to coat the implant. One popular option is to cover the metallic surface with a ceramic. One commercially available ceramic-coated prosthesis is coated with oxidized zirconium, with the trade name Oxinium. Although pseudotumor and metallosis resulting from ceramic joint arthroplasty implants have been documented, there is limited information on the occurrence of metallosis resulting from ceramic-coated knee implants. The purpose of this case report is to discuss a potential differential diagnosis for lower leg mass after total knee arthroplasty and to present a novel case of catastrophic failure of an Oxinium-coated total knee prosthesis (Smith and Nephew) that resulted in metallosis with extra-articular extravasation along the extensor digitorum longus tendon.
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Affiliation(s)
- Amanda Purcell
- Texas Tech University Health Sciences Center, Department of Orthopaedic Surgery and Rehabilitation, Lubbock, TX, USA
| | - Shelby Buckner
- Texas Tech University Health Sciences Center, School of Medicine, Lubbock, TX, USA
| | - George Brindley
- Texas Tech University Health Sciences Center, Department of Orthopaedic Surgery and Rehabilitation, Lubbock, TX, USA
| | - Jerry Grimes
- Texas Tech University Health Sciences Center, Department of Orthopaedic Surgery and Rehabilitation, Lubbock, TX, USA
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9
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Sahan I, Anagnostakos K. Metallosis after knee replacement: a review. Arch Orthop Trauma Surg 2020; 140:1791-1808. [PMID: 32715399 DOI: 10.1007/s00402-020-03560-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/20/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Although metallosis is a well-known complication after total hip arthroplasty, little is known about this phenomenon after total (TKA) or unicompartmental knee arthroplasty (UKA). The aim of the present work was to review the current knowledge about the reasons and the diagnostic as well as therapeutic management of metallosis after knee arthroplasty. MATERIALS AND METHODS A literature search was performed through PubMed until April 2019. Search terms were "metallosis" in combination with "knee", "knee prosthesis", "knee arthroplasty" and "knee replacement", respectively. All publications were analyzed regarding publication year, level of evidence, number of knees/patients treated, type of prosthesis, metallosis cause, time period between primary implantation and metallosis emergence, laboratory examination, treatment, complications and follow up. RESULTS A total of 38 studies reporting on a total of 97 knees were identified. 29 studies reported on metallosis after TKA, 8 after UKA, and one study after both procedures. The time period between the primary implantation and metallosis emergence ranged between 6 weeks and 26 years. The most common reason was the failure of a metal-backed patellar component in 40%, followed by implant/structural- and PE failure (wear/dislocation) in 27% and 18% of the cases, respectively. Complete blood cell count, serum chemistry, erythrocyte sedimentation rate or C-reactive protein serum values were not indicative to diagnose metallosis. The diagnosis was confirmed by histopathological analyses and macroscopic evaluation during surgery. Depending on the particular cause various surgical procedures have been performed. Complete prosthesis exchange was the most common one showing no complications in 89.4% of the cases. CONCLUSIONS Metallosis after knee arthroplasty is a rare and perhaps underestimated or under published complication. A systematic diagnostic approach is necessary for the timely and correct diagnosis. A thorough debridement as well as a (sub)total synovectomy should be always performed. In cases with a damaged component, a partial/complete prosthesis exchange leads to the best results. Should a malalignment be the cause of the metallosis, then it should be corrected within the revision surgery.
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Affiliation(s)
- Ismail Sahan
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Saarbrücken, Winterberg 1, 66119, Saarbrücken, Germany.
| | - Konstantinos Anagnostakos
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Saarbrücken, Winterberg 1, 66119, Saarbrücken, Germany
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10
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Kore L, Bates T, Mills G, Lybeck D. Oxidized Zirconium Total Knee Arthroplasty Implant Failure in a Patient With Knee Instability. Arthroplast Today 2020; 6:552-555. [PMID: 32775586 PMCID: PMC7397700 DOI: 10.1016/j.artd.2020.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/21/2020] [Accepted: 06/29/2020] [Indexed: 11/03/2022] Open
Abstract
Oxidized zirconium was introduced as an alternative bearing surface to decrease polyethylene wear and reduce aseptic mechanical failure of hip and knee arthroplasties. Oxidized zirconium combines the strength of a metal with wear properties of ceramic, proposing increased survivorship of implant components, and possible decreased rate of revision. Despite a harder surface than cobalt-chromium, the substrate of zirconium is a softer metal. Although uncommon, prior reports have described accelerated wear and severe metallosis after femoral head dislocation in oxidized zirconium total hip arthroplasty; however, this has not been described in total knee arthroplasty. We report a case of an oxidized zirconium total knee arthroplasty failure in a patient with knee instability. This is the first report of catastrophic failure of an oxidized zirconium total knee arthroplasty implant.
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Affiliation(s)
- Lydia Kore
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Taylor Bates
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Gavin Mills
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Dustin Lybeck
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX
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11
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Salem KH, Lindner N, Tingart M, Elmoghazy AD. Severe metallosis-related osteolysis as a cause of failure after total knee replacement. J Clin Orthop Trauma 2020; 11:165-170. [PMID: 32002007 PMCID: PMC6985032 DOI: 10.1016/j.jcot.2019.04.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/15/2019] [Accepted: 04/17/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Metallosis is a syndrome of metal-induced synovitis caused by friction between two metal surfaces. In contrast to the hip joint after resurfacing arthroplasty or metal-on-metal (MoM) total hip replacement, metallosis of the knee is extremely rare. MATERIALS We describe 4 patients who underwent revision total knee replacement because of disabling pain and implant loosening after a mean time of 21 (range: 13-30) years of knee replacement surgery. They were all females with a mean age of 79 (range: 75-82) years. Septic loosening was excluded through microbiological examination and synovial fluid analysis. RESULTS Direct metal-on-metal contact at the tibiofemoral interface was confirmed intraoperatively in all cases. All knees showed severe metallosis with advanced osteolysis and pseudotumor formation. In one knee there was a complete fracture of the tibial tray. All patients had a one-stage revision surgery with implant removal, profound synovectomy and implantation of a constrained modular revision knee system. Long modular stems with offset adapters, wedges and/or blocks were used in all cases. CONCLUSION Metallosis-associated osteolysis should be suspected in cases with radiologically evident polyethylene wear after knee replacement. Recognizing that revision arthroplasty is very technically demanding in such cases, surgeons should have a back-up with modular revision components and a ready access to reconstructive options at this revision setting.
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Affiliation(s)
- Khaled Hamed Salem
- Department of Orthopaedic Surgery, Faculty of Medicine, Cairo University, Egypt,Department of Orthopaedic Surgery, Brüderkrankenhaus St. Josef Paderborn, Germany,Department of Orthopaedic Surgery, RWTH Aachen University, Germany,Corresponding author. Department of Orthopaedic Surgery Brüderkrankenhaus St. Josef Paderborn Husener Str. 46, 33098, Paderborn, Germany.
| | - Norbert Lindner
- Department of Orthopaedic Surgery, Brüderkrankenhaus St. Josef Paderborn, Germany
| | - Markus Tingart
- Department of Orthopaedic Surgery, RWTH Aachen University, Germany
| | - Alyaa Diaa Elmoghazy
- Department of Orthopaedic Surgery, Brüderkrankenhaus St. Josef Paderborn, Germany,Department of Orthopaedic Surgery, RWTH Aachen University, Germany
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12
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Kurmis AP, Herman A, McIntyre AR, Masri BA, Garbuz DS. Pseudotumors and High-Grade Aseptic Lymphocyte-Dominated Vasculitis-Associated Lesions Around Total Knee Replacements Identified at Aseptic Revision Surgery: Findings of a Large-Scale Histologic Review. J Arthroplasty 2019; 34:2434-2438. [PMID: 31178384 DOI: 10.1016/j.arth.2019.05.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 05/04/2019] [Accepted: 05/14/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) development (including pseudotumors) secondary to metal debris generation around total hip arthroplasties is a well-recognized histopathologic phenomenon. Emerging data have highlighted a similar potential concern around TKAs although the body-of-knowledge has largely been limited to individual case reports or small retrospective case series. This study sought to establish the prevalence of pseudotumors or high-grade ALVALs seen at the revision of primary TKAs and to establish the correlation between histologic ALVAL grade and patient-reported functional outcome measures. METHODS The findings of 321 non-infective (aseptic) patients undergoing unilateral revision knee surgery, at a high-volume tertiary referral center, were reviewed. Each case was independently histologically classified. Complete patient-reported functional outcome measures were available for 134 patients (42%) allowing correlation between functional performance and histopathology results. RESULTS Five distinct pseudotumors and a further 18 high-grade ALVALs were histologically identified representing 1.6% and 5.6% of the cohort, respectively. When compared by histologic grade, Oxford Knee Score and Western Ontario and McMaster University's Osteoarthritis Index suggested a high correlation between ALVAL grade and functional knee scores. CONCLUSION These findings suggest a prevalence of pseudotumors or high-grade ALVALs at revision TKA surgery of >7%. This unexpectedly high result may contribute insight into the previously under-appreciated significance of metal debris-related local tissue reactions around TKAs. The findings also demonstrate a strong near-linear inverse relationship between patient-reported clinical knee performance and the underlying histologic grade of local tissue reaction. These results have potential management implications for patients with underperforming TKAs and should prompt consideration of an ALVAL secondary to metallosis in the differential diagnosis. LEVEL OF EVIDENCE This is a retrospective cohort study with Level III evidence.
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Affiliation(s)
- Andrew P Kurmis
- Discipline of Medical Specialties, University of Adelaide, Adelaide, South Australia, Australia
| | - Amir Herman
- Department of Orthopaedics, Assuta Medical Centre, Ashdod, Israel
| | - Adam R McIntyre
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald S Garbuz
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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13
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Puente Reyna AL, Fritz B, Schwiesau J, Schilling C, Summer B, Thomas P, Grupp TM. Metal ion release barrier function and biotribological evaluation of a zirconium nitride multilayer coated knee implant under highly demanding activities wear simulation. J Biomech 2018; 79:88-96. [DOI: 10.1016/j.jbiomech.2018.07.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/20/2018] [Accepted: 07/31/2018] [Indexed: 12/13/2022]
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14
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Catastrophic metallosis after tumoral knee prosthesis failure: A case report. Int J Surg Case Rep 2016; 30:9-12. [PMID: 27898357 PMCID: PMC5129503 DOI: 10.1016/j.ijscr.2016.11.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/13/2016] [Accepted: 11/13/2016] [Indexed: 11/26/2022] Open
Abstract
A rare case of huge metallosis is presented. If prosthesis brackage is detected, revision surgery should be attempted. A regular follow-up after surgery it’s the best way to success.
Introduction Metallosis is a condition characterized by an infiltration of periprosthetic soft tissues and bone by metallic debris resulting from wear or failure of joint arthroplasties. Presentation of case Authors describe a case of a 45-year-old man treated for an osteosarcoma of the distal femur with a modular prosthesis when he was 18 years old, he developed massive metallosis with skin dyspigmentation after 17 years. His medical\surgical history was remarkable for a left tumoral knee prosthesis implanted 21 years ago. Two years before revision, the patient had a car accident with a two-points prosthesis breakage and despite the surgeon’s advice, the patient refused surgery. In two years, prosthesis malfunction caused a progressive catastrophic soft tissues infiltration of metallic debris. Discussion and conclusion Authors suggest that if prosthesis fracture is detected, revision surgery should be attempted as earlier as possible.
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15
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Helito CP, Buarque de Gusmão CV, Angelini FJ, Tirico LEP, Pécora JR. Severe metallosis following total knee arthroplasty: a case report and review of radiographic signs. Skeletal Radiol 2014; 43:1169-73. [PMID: 24664480 DOI: 10.1007/s00256-014-1860-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 02/12/2014] [Accepted: 02/28/2014] [Indexed: 02/02/2023]
Abstract
Metallosis is an uncommon complication following total knee arthroplasty that leads to osteolysis and implant loosening due to chronic inflammatory reaction. Abrasion between the metallic surfaces of the implant releases metallic debris that interacts with the periprosthetic soft tissues and causes chronic synovitis. Here we present a case of a 65-year-old man who had undergone total knee arthroplasty 10 years ago and developed implant loosening associated with severe metallosis and varus instability. Radiographs show the three typical signs of metallosis: metal-line sign, bubble sign, and cloud sign. This patient was subjected to revision surgery consisting of debridement and primary implant replacement by a hinged endoprosthesis. Knowledge of the typical radiographic and clinical findings of metallosis is important to rapidly diagnose this complication and avoid progressive joint destruction.
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Affiliation(s)
- Camilo Partezani Helito
- Institute of Orthopaedics and Traumatology, Faculty of Medicine, University of São Paulo, Sao Paulo, Sao Paulo, Brazil
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Abstract
INTRODUCTION The management of bone loss is a crucial aspect of the revision knee arthroplasty. Bone loss can hinder the correct positioning and alignment of the prosthetic components, and can prevent the achievement of a stable bone-implant interface. There is still controversy regarding the optimal management of knee periprosthetic bone loss, especially in large defects for which structural grafts, metal or tantalum augments, tantalum cones, porous metaphyseal sleeves, and special prostheses have been advocated. The aim of this review was to analyze all possible causes of bone loss and the most advanced strategies for managing bony deficiency within the knee joint reconstruction. MATERIALS AND METHODS Most significant and recent papers about the management of bone defects during revision knee arthroplasty were carefully analyzed and reviewed to report the most common causes of bone loss and the most effective strategies to manage them. RESULTS Modular metal and tantalum augmentation showed to provide more stable and durable knee revisions compared to allografts, limited by complications such as graft failure, fracture and resorption. Moreover, modular augmentation may considerably shorten operative times with a potential decrease of complications, above all infection which has been frequently associated to the use of allografts. CONCLUSIONS Modular augmentation may significantly reduce the need for allografting, whose complications appear to limit the long-term success of knee revisions.
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Bonutti PM, Pivec R, Issa K, Kapadia BH, Banerjee S, Harwin SF, Mont MA, Bauer TW. Delamination of tantalum porous coating from a TKA due to regional dissemination of debris. Orthopedics 2013; 36:600-4. [PMID: 23937736 DOI: 10.3928/01477447-20130724-03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Metallic debris from metal-on-metal bearings is a recognized mode of failure that may lead to implant loosening and periprosthetic soft tissue reactions. The sequelae of metallosis have been most commonly reported with respect to total hip arthroplasty. The authors report a rare case of metallosis following a hybrid metal-on-polyethylene total knee arthroplasty that used a porous tantalum tibial knee component. A total knee arthroplasty patient who presented with knee pain but normal radiographs was found to have delamination of her tibial component that resulted in marked periprosthetic soft tissue metallosis.
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Rokitansky AM, Stanek R. Modified minimally invasive pectus repair in children, adolescents and adults: an analysis of 262 patients. Eur Surg 2012. [DOI: 10.1007/s10353-012-0099-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Maccauro G, Tripodi D, Saggini A, Conti F, Cianchetti E, Angelucci D, Rosati M, Toniato E, Fulcheri M, Tetè S, Salini V, Caraffa A, Antinolfi P, Frydas S, Conti P, Theoharides T. Calcium Ionophore A23187 and Compound 48/80 Induce PGD2 and Tryptase in Human Cord Blood-Derived Mast Cells: Lack of Effect of IL-18. EUR J INFLAMM 2012. [DOI: 10.1177/1721727x1201000104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Immunological and biochemical reactions associated with inflammation are elicited in response to a physical or immunological challenge. Early in inflammation there is mobilization and infiltration of neutrophils, mast cells and macrophages to the site of inflammation. These cells release pro-inflammatory compounds icluding cytokines, vasoactive peptides (eg., histamine), and eicosanoids. The release of prostaglandin D2 (PGD2) and tryptase induced by anti-IgE, A23187 and compound 48/80 were studied using in vitro a good and valid model of human cord blood-derived mast cells (HCBDMC). Tryptase is a mast cell product and enhances vasopermeability with anticoagulant activities. In this study we measure the release of PGD2 and tryptase on mast cells activate by anti-IgE, calcium ionophore A23187, polybasic compound 48/80 (an agent containing a cationic region adjacent to a hydrophobic moiety, which works by activating G proteins) and IL-18. The generation of PGD2 was measured by radioimmunoassay. Release of PGD2 was detectable (after 12 h) following challenge with anti-IgE, A23187 and compound 48/80. Our data show that mature HCBDMC produce proinflammatory PGD2 following triggering with anti-IgE and with IgE-independent agonists, such as calcium ionophore A23187 and polybasic compound 48/80, while IL-18 was unable to stimulate the release of PGD2 or tryptase on HCBDMC. Although a great deal has been learned about the mediators produced by mast cells, the ultimate biologic function(s) of mast cells remains a mystery.
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Affiliation(s)
- G. Maccauro
- Orthopedics Division, Università Cattolica, Rome, Italy
| | - D. Tripodi
- Dental School, University of Chieti-Pescara, Italy
| | - A. Saggini
- Department of Dermatology, University of Rome Tor Vergata, Rome, Italy
| | - F. Conti
- Gynecology Division, Pescara Hospital, Pescara, Italy
| | - E. Cianchetti
- Ortona Hospital, University of Chieti-Pescara, Italy
| | - D. Angelucci
- Pathological Anatomy, Chieti Hospital, Chieti, Italy
| | - M. Rosati
- Gynecology Division, Pescara Hospital, Pescara, Italy
| | - E. Toniato
- Immunology Division, University of Chieti-Pescara, Italy
| | | | - S. Tetè
- Dental School, University of Chieti-Pescara, Italy
| | - V. Salini
- Orthopedics Division, University of Chieti-Pescara, Italy
| | - A. Caraffa
- Orthopedics Division, University of Perugia, Perugia, Italy
| | - P. Antinolfi
- Orthopedics Division, University of Perugia, Perugia, Italy
| | - S. Frydas
- Laboratory of Parasitology, Veterinary Faculty, Aristotelian University, Thessaloniki, Greece
| | - P. Conti
- Immunology Division, University of Chieti-Pescara, Italy
| | - T.C. Theoharides
- Department of Physiology and Pharmacology, Tufts University School of Medicine, New England Medical Center, Boston, MA, USA
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