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Burgos J, Hevia E, Sanpera I, García V, de Santos Moreno MT, Mariscal G, Barrios C. Elevated blood metal ion levels in patients undergoing instrumented spinal surgery: a systematic review and meta-analysis. Spine J 2024; 24:947-960. [PMID: 38437920 DOI: 10.1016/j.spinee.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/24/2024] [Accepted: 02/25/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND CONTEXT Elevated blood metal levels have been reported in patients after spinal surgery using metallic implants. Although some studies have suggested an association between heightened blood metal concentrations and potential adverse effects, estimates of the incidence of abnormal metal levels after spinal surgery have been inconsistent. PURPOSE The aims of this systematic review and meta-analysis were to assess: (1) mean differences in blood metal ion levels between patients undergoing spinal fusion surgery and healthy controls, (2) odds of elevated blood metal ion levels after surgery compared to presurgery levels, and (3) pooled incidence of elevated blood metal ions overall and by metal type. STUDY DESIGN Systematic review and meta-analysis. PATIENTS SAMPLE The patient sample included 613 patients from 11 studies who underwent spinal surgery instrumentation. OUTCOME MEASURES Blood metal ion concentrations and the incidence of patients with elevated metal levels compared with in those the control group. METHODS A comprehensive search was conducted in PubMed, EMBASE, Scopus, and Cochrane Library to identify studies reporting blood metal ion levels after spinal fusion surgery. Mean differences (MD), odds ratios (OR), and incidence rates were pooled using random effects models. Heterogeneity was assessed using I2 statistics, and fixed-effects models were used if no heterogeneity was detected. Detailed statistical analysis was performed using the Review Manager version 5.4 software. RESULTS The analysis included 11 studies, with a total of 613 patients. Mean blood metal ion levels were significantly higher after spinal fusion surgery (MD 0.56, 95% CI 0.17-0.96; I2=86%). Specifically, titanium levels were significantly elevated (MD 0.81, 95% CI 0.32-1.30; I2=47%). The odds of elevated blood metal ions were higher after surgery (OR 8.17, 95% CI 3.38-19.72; I2=41%), primarily driven by chromium (OR 23.50, 95% CI 5.56-99.31; I2=30%). The incidence of elevated chromium levels was found to be 66.98% (95% CI 42.31-91.65). CONCLUSION In conclusion, blood metal ion levels, particularly titanium and chromium, were significantly increased after spinal fusion surgery compared to presurgery levels and healthy controls. Approximately 70% of the patients exhibited elevated blood levels of chromium and titanium.
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Affiliation(s)
- Jesús Burgos
- Vithas Internacional, C/ de Arturo Soria, 107, Cdad. Lineal, 28043 Madrid, Spain
| | - Eduardo Hevia
- Spine Unit, University of Navarra Clinic, C. del Marquesado de Sta. Marta, 1, San Blas-Canillejas, 28027, Madrid, Spain
| | - Ignacio Sanpera
- Pediatric Orthopedics, Son Espases Hospital, Spain de Valldemossa, 79, Nord, 07120 Palma, Illes Balears, Spain
| | - Vicente García
- Spine Surgery Section, Araba University Hospital, Jose Atxotegi Kalea, s/n, Txagorritxu, 01009 Gasteiz, Araba, Spain
| | - María Teresa de Santos Moreno
- Neuropediatrics Unit, San Carlos Clinic Hospital, Calle del Prof Martín Lagos, S/N, Moncloa - Aravaca, 28040 Madrid, Spain
| | - Gonzalo Mariscal
- Mediterranean Observatory for Clinical and Health Research (OMEDICS), Carrer Quevedo 1, 46001, Valencia, Spain; Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, C/ de Quevedo, 2, Ciutat Vella, 46001 Valencia, Spain.
| | - Carlos Barrios
- Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, C/ de Quevedo, 2, Ciutat Vella, 46001 Valencia, Spain
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Edlinger C, Paar V, Kheder SH, Krizanic F, Lalou E, Boxhammer E, Butter C, Dworok V, Bannehr M, Hoppe UC, Kopp K, Lichtenauer M. Endothelialization and Inflammatory Reactions After Intracardiac Device Implantation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1401:1-22. [DOI: 10.1007/5584_2022_712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shen M, Zhang C, Yi X, Guo J, Xu S, Huang Z, He M, Chen X, Luo D, Yang F. Association of multi-metals exposure with intelligence quotient score of children: A prospective cohort study. ENVIRONMENT INTERNATIONAL 2021; 155:106692. [PMID: 34148013 DOI: 10.1016/j.envint.2021.106692] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 05/23/2023]
Abstract
BACKGROUND Associations between most single metals and children's intelligence quotient (IQ) scores have been evaluated in previous studies. However, associations between multi-metal exposures and children's IQ scores have not been analyzed. OBJECTIVES To assess the joint effects of lead (Pb), manganese (Mn), antimony (Sb), tin (Sn) and titanium (Ti) co-exposure on children's IQ scores. METHODS A prospective cohort study was conducted in Shimen and Huayuan, Hunan Province, China. Urine metals levels were measured by inductively coupled plasma mass spectrometry (ICP-MS) at baseline. Children's IQ scores were repeatedly measured at baseline and follow-up following the method of Raven's Standard Progressive Matrices (SPM) and standardized as z scores. We fitted linear regression models and Bayesian kernel machine regression (BKMR) models to investigate the associations of metal levels with children's IQ scores after adjusting for covariates. RESULTS A total of 633 participants aged 7-10 years completed the survey. Urinary Pb (β = -0.028, P = 0.022) and urinary Ti (β = -0.0003, P = 0.001) were inversely associated with children's IQ scores. The BKMR analyses revealed significant negative overall effects of the five metals on children's IQ scores when all the metals were above their median levels, while significant positive associations were shown when all the metal concentrations were below their median levels. The model also showed negative trends of Sn and Ti on children's IQ. Furthermore, Ti and Sn had a synergistic relationship, with a decline in IQ score when Sn exposure was relatively high. The urinary Sn concentration was significantly higher but the urinary Ti concentration was significantly lower in participants from the Shimen area than in those from the Huayuan area. Decreasing trends of the overall effects were observed in both the Shimen and Huayuan areas. CONCLUSION Our findings revealed that multi-metal exposures caused a decline in children's IQ scores according to traditional linear regression models and the BKMR model. Our results provide some evidence of the association between multi-metal exposure and children's IQ. Meanwhile, interactions between multi-metal exposures on children's IQ should be given more attention.
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Affiliation(s)
- Minxue Shen
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, China; Department of Dermatology, Xiangya Hospital, Central South University, Changsha, China.
| | - Chengcheng Zhang
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, China; Department of Occupational and Environmental Health, Xiangya School of Public Health, Central South University, Changsha, China
| | - Xiping Yi
- Department of Occupational and Environmental Health, Xiangya School of Public Health, Central South University, Changsha, China
| | - Jian Guo
- Department of Occupational and Environmental Health, Xiangya School of Public Health, Central South University, Changsha, China
| | - Shuaishuai Xu
- Department of Occupational and Environmental Health, Xiangya School of Public Health, Central South University, Changsha, China
| | - Zhijun Huang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Meian He
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang Chen
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, China.
| | - Dan Luo
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, China.
| | - Fei Yang
- Department of Occupational and Environmental Health, Xiangya School of Public Health, Central South University, Changsha, China; Hunan Province Key Laboratory of Typical Environmental Pollution and Health Hazards, School of Public Health, Hengyang Medical College, University of South China, Hengyang 421001, China.
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Badhe RV, Akinfosile O, Bijukumar D, Barba M, Mathew MT. Systemic toxicity eliciting metal ion levels from metallic implants and orthopedic devices - A mini review. Toxicol Lett 2021; 350:213-224. [PMID: 34252509 DOI: 10.1016/j.toxlet.2021.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 06/19/2021] [Accepted: 07/07/2021] [Indexed: 12/28/2022]
Abstract
The metal/metal alloy-based implants and prostheses are in use for over a century, and the rejections, revisions, and metal particle-based toxicities were reported concurrently. Complications developed due to metal ions, metal debris, and organo-metallic particles in orthopedic patients have been a growing concern in recent years. It was reported that local and systemic toxicity caused by such released products from the implants is one of the major reasons for implant rejection and revision. Even though the description of environmental metal toxicants and safety limits for their exposure to humans were well established in the literature, an effort was not adequately performed in the case of implant-based metal toxicology. Since the metal ion concentration in serum acts as a possible indicator of the systemic toxicity, this review summarizes the reported human serum safe limits, toxic limits, and concentration range (μg/L, ppb, etc.) for mild to severe symptoms of six (cardiac, hepatic, neuro, nephron, dermal and endocrine) systemic toxicities for twelve most commonly used metallic implants. It also covers the widely used metal ion quantification techniques and systemic toxicity treatments reported.
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Affiliation(s)
- Ravindra V Badhe
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, IL, USA
| | - Obakanyin Akinfosile
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, IL, USA
| | - Divya Bijukumar
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, IL, USA
| | | | - Mathew T Mathew
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, IL, USA.
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Danielewicz A, Wójciak M, Sawicki J, Dresler S, Sowa I, Latalski M. Comparison of Different Surgical Systems for Treatment of Early-onset Scoliosis in the Context of Release of Titanium Ions. Spine (Phila Pa 1976) 2021; 46:E594-E601. [PMID: 33290378 PMCID: PMC8614546 DOI: 10.1097/brs.0000000000003846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/04/2020] [Accepted: 10/08/2020] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case-control study. OBJECTIVE The aim of the study was to compare growth-friendly systems: traditional growing rod, guided growth systems (GGS), and vertical expandable prosthetic titanium rib in the context of titanium release. SUMMARY OF BACKGROUND DATA The problem of scoliosis affects even up to 3% of the population, and ca. 0.1% of patients need surgical treatment. Surgical treatment carries the risk of a long-term presence of implants in the organism, which may result in release of metal ions into the tissues and bloodstream. METHODS Seventy-one patients (13.5 ± 3.54 years' old) were treated for spinal deformity using various surgical systems and the samples of paraspinal tissue, blood, nails, and hair were collected before and after treatment. The quantification of titanium was performed using inductively coupled plasma optical emission spectrometry. RESULTS The metallic particles were released into the peri-implant tissue, and the greatest amounts of titanium were detected in patients with GGS. The concentration of soluble titanium forms in subcutaneous tissue (ST) was low and do not statistically differ from control. The average titanium content in the paraspinal tissue in patients with GGS was two- to three-fold higher than the average value in the other investigated groups. A slightly increased level of titanium compared with the control was noted in all studied groups of patients. The highest content of titanium in blood was observed in patients with the GGS system. CONCLUSION Neverless the system used, the concentration of soluble titanium forms in both ST and blood was only slightly higher than in the control and did not exceed the allowable levels. The increased level of titanium with GGS system is probably associated with the friction between implant components, whereas the components in the other systems are immobile relative to each other.Level of Evidence: 3.
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Affiliation(s)
- Anna Danielewicz
- Department of Paediatric Orthopaedics, Medical University of Lublin, Lublin, Poland
| | - Magdalena Wójciak
- Department of Analytical Chemistry, Medical University of Lublin, Lublin, Poland
| | - Jan Sawicki
- Department of Analytical Chemistry, Medical University of Lublin, Lublin, Poland
| | - Sławomir Dresler
- Department of Analytical Chemistry, Medical University of Lublin, Lublin, Poland
| | - Ireneusz Sowa
- Department of Analytical Chemistry, Medical University of Lublin, Lublin, Poland
| | - Michał Latalski
- Department of Paediatric Orthopaedics, Medical University of Lublin, Lublin, Poland
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Analysis of serum levels of titanium and aluminium ions in patients with early onset scoliosis operated upon using the magnetic growing rod-a single centre study of 14 patients. Spine Deform 2021; 9:1473-1478. [PMID: 34297320 PMCID: PMC8363538 DOI: 10.1007/s43390-021-00335-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/15/2021] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN A cross-sectional retrospective Level 3 study. OBJECTIVE To study the serum levels of Titanium and Aluminium ions in patients operated using the magnetically controlled growing rod (MCGR) system. 14 consecutive patients of early onset scoliosis with varying etiology managed with MCGR system with a minimum follow-up of 24 months were selected for the study. The group consisted of two boys (14.3%) and 12 girls (85.7%). The average age of the patients at the time of surgery was 10.4 years (5-15 years). The average period of follow-up was 43.7 months (28-79 months). After informed consent of the subjects and their caretakers, serum levels of titanium and aluminium were measured. These levels were then assessed with regards to the number of screws used, number of distractions and complications. METHODS The concentration of titanium and aluminium ions in the serum was measured using high resolution inductively coupled plasma mass spectrometry. RESULTS For the sake of ease of assessment, patients were divided into three etiology-based groups-idiopathic (n = 6), neuromuscular (n = 2) and syndromic (n = 6). The mean serum titanium level was 15.9 μg/L (5.1-28.2 μg/L) while that of aluminium was 0.1 μmol/L (0.1-0.2 μmol/L). Of the 14 patients, 2 (14.2%) patients had mechanical failure (actuator pin dysfunction), 3 (21.4%) had rod breakage requiring revision surgery and one patient (7.1%) had surgical site infection managed with appropriate antibiotics. Patients undergoing revision for rod breakage did not show any metallosis of the tissues during surgery. CONCLUSION Analysis of patients with scoliosis operated using the magnetic growing rod system concludes that it is accompanied by presence of titanium in the blood but whether clinically significant or not needs to be ascertained by comparison of preoperative and postoperative blood concentrations of the titanium ions in individual subjects. The aluminium ion concentration remains within normal limits. Though implant malfunction may raise the titanium levels in the blood, its clinical significance needs to be determined. The aluminium levels are not affected irrespective to the presence or absence of complications. The long-term effects of raised titanium levels in the blood also warrant further prospective studies designed for precise and deeper analyses.
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Siddiqi O, Urquhart JC, Rasoulinejad P. A systematic review of metal ion concentrations following instrumented spinal fusion. Spine Deform 2021; 9:13-40. [PMID: 32780305 DOI: 10.1007/s43390-020-00177-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/27/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Metallic spinal implants undergo wear and corrosion which liberates ionic or particulate metal debris. The purpose of this study was to identify and review studies that report the concentration of metal ions following multi-level spinal fusion and to evaluate the impact on clinical outcomes. METHODS Databases (PubMed, EBSCO MEDLINE) were searched up to August 2019 for studies in English-language assessing metal ion levels [chromium (Cr), titanium (Ti), nickel (Ni)] in whole blood, serum, or plasma after spinal fusion using a specific search string. Study, patient, and implant characteristics, method of analysis, metal ion concentration, as well as clinical and radiographic results was extracted. RESULTS The systematic search yielded 18 studies encompassing 653 patients. 9 studies reported Ti ions, eight reported Cr, and six reported Ni. Ti levels were elevated compared to controls/reference range/preoperative baseline in seven studies with the other two reporting no difference. Cr levels were elevated compared to controls/reference range in seven studies with one reporting no difference. Ni levels showed no difference from controls/reference range in four studies with one reporting above normal and another elevated compared to controls. Radiographic evidence of corrosion, implant failure, pseudarthrosis, revision surgery and adverse reaction reporting was highly variable. CONCLUSION Metal ions are elevated after instrumented spinal fusion; notably Cr levels from stainless steel implants and Ti from titanium implants. The association between clinical and radiographic outcomes remain uncertain but is concerning. Further research with standardized reporting over longer follow-up periods is indicated to evaluate the clinical impact and minimizing risk.
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Affiliation(s)
| | - Jennifer C Urquhart
- Department of Surgery, London Health Sciences Center, E1-311, 800 Commissioners Road, East, London, ON, N6A 4G5, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Parham Rasoulinejad
- Department of Surgery, London Health Sciences Center, E1-311, 800 Commissioners Road, East, London, ON, N6A 4G5, Canada. .,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. .,Lawson Health Research Institute, London, ON, Canada.
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Markowska-Szczupak A, Endo-Kimura M, Paszkiewicz O, Kowalska E. Are Titania Photocatalysts and Titanium Implants Safe? Review on the Toxicity of Titanium Compounds. NANOMATERIALS 2020; 10:nano10102065. [PMID: 33086609 PMCID: PMC7603142 DOI: 10.3390/nano10102065] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 12/11/2022]
Abstract
Titanium and its compounds are broadly used in both industrial and domestic products, including jet engines, missiles, prostheses, implants, pigments, cosmetics, food, and photocatalysts for environmental purification and solar energy conversion. Although titanium/titania-containing materials are usually safe for human, animals and environment, increasing concerns on their negative impacts have been postulated. Accordingly, this review covers current knowledge on the toxicity of titania and titanium, in which the behaviour, bioavailability, mechanisms of action, and environmental impacts have been discussed in detail, considering both light and dark conditions. Consequently, the following conclusions have been drawn: (i) titania photocatalysts rarely cause health and environmental problems; (ii) despite the lack of proof, the possible carcinogenicity of titania powders to humans is considered by some authorities; (iii) titanium alloys, commonly applied as implant materials, possess a relatively low health risk; (iv) titania microparticles are less toxic than nanoparticles, independent of the means of exposure; (v) excessive accumulation of titanium in the environment cannot be ignored; (vi) titanium/titania-containing products should be clearly marked with health warning labels, especially for pregnant women and young children; (vi) a key knowledge gap is the lack of comprehensive data about the environmental content and the influence of titania/titanium on biodiversity and the ecological functioning of terrestrial and aquatic ecosystems.
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Affiliation(s)
- Agata Markowska-Szczupak
- Department of Chemical and Process Engineering, West Pomeranian University of Technology in Szczecin, Al. Piastów 42, 71-065 Szczecin, Poland;
- Correspondence: (A.M.-S.); (E.K.)
| | - Maya Endo-Kimura
- Institute for Catalysis, Hokkaido University, N21, W10, Sapporo 001-0021, Japan;
| | - Oliwia Paszkiewicz
- Department of Chemical and Process Engineering, West Pomeranian University of Technology in Szczecin, Al. Piastów 42, 71-065 Szczecin, Poland;
| | - Ewa Kowalska
- Institute for Catalysis, Hokkaido University, N21, W10, Sapporo 001-0021, Japan;
- Correspondence: (A.M.-S.); (E.K.)
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Dover C, Kuiper JH, Craig P, Shaylor P. Ten years on: increased metal ion levels in a cohort of patients who underwent uncemented metal-on-polyethylene total hip arthroplasty. Bone Joint J 2020; 102-B:832-837. [DOI: 10.1302/0301-620x.102b7.bjj-2019-1372.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims We have previously demonstrated raised cobalt and chromium levels in patients with larger diameter femoral heads, following metal-on-polyethylene uncemented total hip arthroplasty. Further data have been collected, to see whether these associations have altered with time and to determine the long-term implications for these patients and our practice. Methods Patients from our previous study who underwent Trident-Accolade primary total hip arthroplasties using a metal-on-polyethylene bearing in 2009 were reviewed. Patients were invited to have their cobalt and chromium levels retested, and were provided an Oxford Hip Score. Serum ion levels were then compared between groups (28 mm, 36 mm, and 40 mm heads) and over time. Results Metal ion levels were repeated in 33 patients. When comparing the results of serum metal ion levels over time, regardless of head size, there was a significant increase in both cobalt and chromium levels (p < 0.001). Two patients with larger head sizes had undergone revision arthroplasty with evidence of trunnion damage at surgery. Two patients within the 40 mm subgroup had metal ion levels above the MHRA (Medicines and Healthcare Products Regulatory Agency) threshold for detailed investigation. The increase in cobalt and chromium, when comparing the 36 mm and 40 mm groups with those of the 28 mm group, was not significant (36 mm vs 28 mm; p = 0.092/p = 0.191; 40 mm vs 28 mm; p = 0.200/p = 0.091, respectively). There was no difference, between femoral head sizes, when comparing outcome as measured by the Oxford Hip Score. Conclusion This study shows an increase in cobalt and chromium levels over time for all modular femoral head sizes in patients with metal-on-polyethylene bearings, with two patients demonstrating ion levels above the MHRA threshold for failure, and a further two patients requiring revision surgery. These results may have clinical implications regarding longer term follow-up of patients and future implant choice, particularly among younger patients. Cite this article: Bone Joint J 2020;102-B(7):832–837.
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Affiliation(s)
- Caroline Dover
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, UK
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Oswestry, UK
| | - Jan Herman Kuiper
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, UK
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
| | - Peter Craig
- The Holland Orthopaedic and Arthritic Centre, University of Toronto, Toronto, Canada
| | - Phillip Shaylor
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Oswestry, UK
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Fernández Bances I, Paz Aparicio J, Alvarez Vega MA. Evaluation of Titanium Serum Levels in Patients After Spine Instrumentation: Comparison Between Posterolateral and 360º Spinal Fusion Surgery. Cureus 2019; 11:e5451. [PMID: 31511816 PMCID: PMC6716769 DOI: 10.7759/cureus.5451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction The use of orthopedic implants is a cause for concern for the release of its integrating metals and the systemic complications that may occur. Instrumented spine arthrodesis is the recommended treatment for many spine diseases. Different segmental fixation devices, commonly made of titanium and its alloys, are used in these surgeries. The use of this metal for spinal fusion has introduced the possibility of generating microscopic metal particles that are present in the tissues of the surrounding implants (peri-implant environment). In fact, metal debris has been found in the paraspinal soft tissues of patients with posterior lumbar instrumentation and showed to be particularly high in patients undergoing revision procedures of pseudoarthrosis. In addition, part of the metals might also dissolve (either from the released particles or directly from the implant surface) and circulate in the body fluids, accumulating (eventually) in remote organs. Material and methods A prospective study was designed with patients who were to be operated by the pathology of the lumbar spine to perform a vertebral arthrodesis composed of a titanium alloy (n=32). Two subgroups were differentiated according to the type of surgery performed: a) Posterolateral arthrodesis (N=5); b) Circumferential arthrodesis intervertebral implant of polyester-ether ketone (PEEK) (N=8) or titanium (N=19). The blood sample was taken before surgery and one year later. The samples were analyzed by mass spectrophotometry with a double focus inductive coupling plasma source (DF-ICP-MS). Results Blood titanium levels prior to surgery were similar to those in other publications (0.7449 micrograms per liter-1 (µgL-1), Standard Deviation (SD)=0.562). The average titanium concentration levels found after surgery was 2.5406 µgL-1 (SD=3,69), near 3.5-fold increase. After surgery, there was a significant mean increase in serum titanium levels of 1.7957 µgL-1 (SD=3.5765, Range=-0.57 µgL-1; 14.60 µgL-1). There is a statistically significant increment (p=0.00049) of the titanium concentration in the serum of the patients after surgery. If we analyze the patients in three groups according to the type of implants used (posterolateral, circumferential with PEEK, and circumferential with titanium), there are no differences between those who did not have an intersomatic device implanted and those in which PEEK implants were implanted, but with those in which it was titanium it was p=0.006 and p=0.018, respectively. Conclusions Patients undergoing vertebral instrumentation experience a significant increase in serum titanium levels compared to before surgery levels. The use of an intersomatic device did not show differences in titanium release with not using it when it was PEEK. There are significant differences between patients without intersomatic implants or those who had a PEEK implant with those in whom it was titanium, with a significant increase in blood titanium levels.
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Affiliation(s)
| | - José Paz Aparicio
- Spine Unit, Orthopedic Surgery and Traumatology Department, University Central Hospital of Asturias, Oviedo, ESP
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Evaluation of Blood Titanium Levels and Total Bone Contact Area of Dental Implants. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4121639. [PMID: 30046598 PMCID: PMC6038673 DOI: 10.1155/2018/4121639] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/11/2018] [Accepted: 05/02/2018] [Indexed: 12/01/2022]
Abstract
The purpose of this study was to evaluate the effect of total implant-bone surface contact area of dental implants applied on partial or total edentulous patients on the increase in the level of blood titanium level. Changes of the blood titanium levels were evaluated after placement of the dental implants in 30 patients including 15 females and 15 males. Patients were divided into 3 groups as dental implants were applied on only maxilla, only mandible, or both of them. Taking into the consideration anatomic formation and prosthetic indication, dental implant-bone total contact area was calculated and saved for each patient after dental implants placement. Blood samples of the patients taken preoperatively and postoperatively at 12 weeks were analyzed by ICP-MS device. Blood titanium levels of preoperative and postoperative blood samples were analyzed for each patient and results were evaluated statistically. In the evaluation after analyzing blood titanium level changes, while a statistically significant decrease was observed in Group 1 patients, a statistically significant increase was observed in Group 2 and Group 3 patients to blood titanium level. A statistically significant difference was observed between Group 1 and Group 2 and between Group 1 and Group 3 patients of blood titanium levels. The change of the blood titanium level was not related to total implant-bone surface area, number of the implants, and gender. In our study, no correlation was found between change of blood titanium level and total contact area with bone of dental implants. We believe that more accurate results can be obtained with biopsy of tissues and organs on animal studies.
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Saxena M, Loza-Rosas SA, Gaur K, Sharma S, Pérez Otero SC, Tinoco AD. Exploring titanium(IV) chemical proximity to iron(III) to elucidate a function for Ti(IV) in the human body. Coord Chem Rev 2018; 363:109-125. [PMID: 30270932 PMCID: PMC6159949 DOI: 10.1016/j.ccr.2018.03.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite its natural abundance and widespread use as food, paint additive, and in bone implants, no specific biological function of titanium is known in the human body. High concentrations of Ti(IV) could result in cellular toxicity, however, the absence of Ti toxicity in the blood of patients with titanium bone implants indicates the presence of one or more biological mechanisms to mitigate toxicity. Similar to Fe(III), Ti(IV) in blood binds to the iron transport protein serum transferrin (sTf), which gives credence to the possibility of its cellular uptake mechanism by transferrin-directed endocytosis. However, once inside the cell, how sTf bound Ti(IV) is released into the cytoplasm, utilized, or stored remain largely unknown. To explain the molecular mechanisms involved in Ti use in cells we have drawn parallels with those for Fe(III). Based on its chemical similarities with Fe(III), we compare the biological coordination chemistry of Fe(III) and Ti(IV) and hypothesize that Ti(IV) can bind to similar intracellular biomolecules. The comparable ligand affinity profiles suggest that at high Ti(IV) concentrations, Ti(IV) could compete with Fe(III) to bind to biomolecules and would inhibit Fe bioavailability. At the typical Ti concentrations in the body, Ti might exist as a labile pool of Ti(IV) in cells, similar to Fe. Ti could exhibit different types of properties that would determine its cellular functions. We predict some of these functions to mimic those of Fe in the cell and others to be specific to Ti. Bone and cellular speciation and localization studies hint toward various intracellular targets of Ti like phosphoproteins, DNA, ribonucleotide reductase, and ferritin. However, to decipher the exact mechanisms of how Ti might mediate these roles, development of innovative and more sensitive methods are required to track this difficult to trace metal in vivo.
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Affiliation(s)
- Manoj Saxena
- Department of Chemistry, University of Puerto Rico Río Piedras, San Juan, PR 00931
| | - Sergio A. Loza-Rosas
- Department of Chemistry, University of Puerto Rico Río Piedras, San Juan, PR 00931
| | - Kavita Gaur
- Department of Chemistry, University of Puerto Rico Río Piedras, San Juan, PR 00931
| | - Shweta Sharma
- Department of Environmental Sciences, University of Puerto Rico Río Piedras, San Juan, PR 00931
| | - Sofia C. Pérez Otero
- Department of Chemistry, University of Puerto Rico Río Piedras, San Juan, PR 00931
| | - Arthur D. Tinoco
- Department of Chemistry, University of Puerto Rico Río Piedras, San Juan, PR 00931
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Koller D, Bramhall P, Devoy J, Goenaga-Infante H, Harrington CF, Leese E, Morton J, Nuñez S, Rogers J, Sampson B, Powell JJ. Analysis of soluble or titanium dioxide derived titanium levels in human whole blood: consensus from an inter-laboratory comparison. Analyst 2018; 143:5520-5529. [DOI: 10.1039/c8an00824h] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Exposure to titanium (Ti),viathe ingestion of pigment grade Ti dioxide (TiO2), is commonplace for westernised populations.
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Affiliation(s)
- D. Koller
- Biomineral Research Group
- Department of Veterinary Medicine
- University of Cambridge
- Cambridge
- UK
| | - P. Bramhall
- University Hospital of Wales TRACE ELEMENT LABORATORY
- Department of Medical Biochemistry and Immunology
- Cardiff
- UK
| | - J. Devoy
- INRS
- Unité de Génération d'atmosphères et de Chimie Analytique Toxicologique
- 54519 Vandoeuvre-lès-Nancy
- France
| | | | | | - E. Leese
- Health and Safety Executive
- Biological Monitoring
- Buxton
- UK
| | - J. Morton
- Health and Safety Executive
- Biological Monitoring
- Buxton
- UK
| | - S. Nuñez
- LGC Limited
- Inorganic Analysis
- Teddington
- UK
| | - J. Rogers
- University Hospital of Wales TRACE ELEMENT LABORATORY
- Department of Medical Biochemistry and Immunology
- Cardiff
- UK
| | - B. Sampson
- Charing Cross Hospital
- SAS Trace Element Laboratory
- London
- UK
| | - J. J. Powell
- Biomineral Research Group
- Department of Veterinary Medicine
- University of Cambridge
- Cambridge
- UK
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14
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Serum Metal Concentrations in Patients With Titanium Ceramic Composite Cervical Disc Replacements. Spine (Phila Pa 1976) 2017; 42:366-371. [PMID: 27323223 DOI: 10.1097/brs.0000000000001745] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective longitudinal study. OBJECTIVE The serum titanium (Ti) concentrations were examined in patients implanted with a PRESTIGE LP Cervical Disc System (Medtronic, Inc., Memphis, TN). The metal-on-metal disc with ball-in-trough articulation is made of titanium alloy/titanium carbide composite (Ti-6Al-4 V/TiC). SUMMARY OF BACKGROUND DATA Cervical disc arthroplasty provides a motion-preserving treatment alternative to anterior cervical discectomy and fusion for degenerative cervical disc disease. The articulating surfaces have a tendency to generate in vivo wear in the form of insoluble particulates (debris) and soluble metal ions. Not much information is available on the long-term metal concentrations observed in cervical disc arthroplasty and how these compare with the metal concentrations in Ti-based posterior fixation devices and other joint replacement implants. METHODS Thirty patients were enrolled after strict exclusion criteria that included no previous permanent metal implants and no professional exposure to metal particles. High-resolution inductively coupled plasma-mass spectrometry was used to assay blood serum titanium concentrations preoperatively and at 3, 6, 12, 24, 36, 60, and 84 months after surgery. The detection limit for Ti was 0.2 ng/mL. The Friedman test was used to make longitudinal statistical comparisons. RESULTS The median serum Ti concentrations determined preoperatively, and at 3, 6, 12, 24, 36, 60, and 84 months were 0.10, 1.22, 1.15, 1.27, 1.21, 1.46, 1.34, and 1.42 ng/mL, respectively. The serum Ti concentrations at all postoperative time points were significantly higher than that at the preoperative time point (Friedman P < 0.01). CONCLUSION The long-term postoperative serum Ti concentrations were significantly higher than the preoperative concentrations. The observed serum Ti concentrations in this study are lower than the reported concentrations in patients receiving posterior spinal instrumentation and metal or ceramic-on-polyethylene hip prostheses with Ti-alloy based stems and acetabular components. LEVEL OF EVIDENCE 3.
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15
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Metal concentrations in the blood and tissues after implantation of titanium growth guidance sliding instrumentation. Spine J 2016; 16:380-8. [PMID: 26656164 DOI: 10.1016/j.spinee.2015.11.040] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 08/07/2015] [Accepted: 11/18/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Growth guidance sliding treatment devices, such as Shilla (Medtronic, Minneapolis, MN USA) or LSZ-4D (CONMET, Moscow, Russia), used for the treatment of scoliosis in children who have high growth potential have unlocked fixtures that allow rods to slide during growth of the spine, which avoids periodical extensions. However, the probability of clinical complications associated with metallosis after implantation of such devices is poorly understood. The content of metal ions in the blood and tissues of pediatric patients treated for scoliosis using fusionless growth guidance sliding instrumentation has not yet been investigated. PURPOSE The aim of the present study was to measure the content of metal ions in the blood and tissues surrounding the implanted growth guidance sliding LSZ-4D devices made of titanium alloy (Ti6Al4V), and to identify the incidence of metallosis-associated clinical complications in some patients with these devices. STUDY DESIGN This is a one-center, case-control retrospective study. PATIENTS SAMPLE The study group included 25 patients with high growth potential (22 females, 3 males; average age at primary surgery for scoliosis treatment is 11.4±1.2 years old) who had sliding growth guidance instrumentation LSZ-4D (CONMET) implanted on 13 (range: 10-16) spine levels for 6±2 years. The LSZ-4D device was made from titanium alloy Ti6Al4V and consisted of two rectangular section rods and fixture elements. Locked fixtures were used on one spinal level, whereas the others were unlocked (sliding). The control group consisted of 13 patients (12 females and 1 male; 11±1.2 years old) without any implanted devices. OUTCOME MEASURES The content of Ti, Al, and V metal ions in the whole blood and tissues around the implanted device was measured. The incidences of metallosis-associated complications in the study group were recorded. METHODS Metal ion content was measured by the inductively coupled mass spectrometry method on quadrupolar NexION 300D (PerkinElmer Inc, Shelton, CT, USA). RESULTS Five of 25 patients in the study group developed metallosis-associated complications (two sinuses and three seroma in the lumbar part of the spine). Revisions were carried out in two of these patients. Ninety percent of the patients in the study group had increased content of Ti and V ions in the blood (2.8 and 4 times, respectively). Median content of Ti ions in soft tissues adjacentto implanted sliding device was more than 1,500-fold higher than that of the control group. These levels are much higher than previously reported for spinal instrumentation. CONCLUSIONS Increased content of Ti and V ions in the blood and especially in tissues around the titanium growth guidance sliding device LSZ-4D accompanied by clinical manifestations (seroma and sinuses) indicates the importance of improving wear resistance of such instrumentation with the coatings and the necessity to exchange sliding instrumentation once the child is fully grown.
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Golasik M, Herman M, Piekoszewski W. Toxicological aspects of soluble titanium – a review of in vitro and in vivo studies. Metallomics 2016; 8:1227-1242. [DOI: 10.1039/c6mt00110f] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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17
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Lons A, Arnould A, Pommepuy T, Drumez E, Girard J. Excellent short-term results of hip resurfacing in a selected population of young patients. Orthop Traumatol Surg Res 2015; 101:661-5. [PMID: 26362039 DOI: 10.1016/j.otsr.2015.07.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 07/01/2015] [Accepted: 07/17/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hip resurfacing (HR) is an alternative option to total hip arthroplasty (THA) in a population of selected patients (young and/or active). HYPOTHESIS The short-term survivorship rate is as least as good as that for THA with no abnormal increase in serum metal ion levels. MATERIALS AND METHODS A continuous prospective series of 502 hip resurfacings in 481 patients mean age 48.7 years old (±10.3; 18-68) (Conserve Plus, Wright Medical Technology) was analyzed clinically, radiologically and biologically (total blood chrome, cobalt and titanium metal ion levels). Mean follow up was 4.1 years (1.9-4.9). RESULTS There were no dislocations. There were 5 cases of revision surgery with component replacement (including 2 infections). Implant survivorship using implant removal as the criteria (excluding infection) was 99.4% at 4 years (CI 95%: 98.1-99.8). The evaluation of metal ion levels showed a significant increase in cobalt from a preoperative level of 0.24 μg/L (0.01-3.6) to 0.86 μg/L (0.01-5.7) at the final follow-up (P<0.001). Chrome and titanium levels went from 0.68 μg/L (0.01-4.4) and 2.36 μg/L (0.39-7) to 1.28 μg/L (0.1-5.5) and 4.49 μg/L (1.29-8.21) respectively (P<0.001). All clinical scores had significantly improved at the final follow-up. Mean frontal plane cup inclination was 42.7° (35-62). DISCUSSION In a selected population of young and/or active patients, the short-term results of hip resurfacing are excellent. At the postoperative 4-year follow-up the rate of complications (in particular the absence of dislocations) was less than that for THA in young and/or active patients. Certain conditions must be respected to obtain these results; frontal plane cup inclination of between 40 and 45°, a femoral head diameter of at least 48 mm and good quality femoral bone. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- A Lons
- Université Lille Nord de France, 59000 Lille, France; Service d'orthopédie C, hôpital Salengro, place de Verdun, CHU de Lille, 59000 Lille, France
| | - A Arnould
- Université Lille Nord de France, 59000 Lille, France; Service d'orthopédie D, hôpital Salengro, place de Verdun, CHU de Lille, 59000 Lille, France
| | - T Pommepuy
- Université Lille Nord de France, 59000 Lille, France; Service d'orthopédie C, hôpital Salengro, place de Verdun, CHU de Lille, 59000 Lille, France
| | - E Drumez
- Université Lille Nord de France, 59000 Lille, France; Unité biostatistiques pôle santé publique, maison régionale de la recherche clinique, CERIM, 154, rue du Docteur-Yersin, 59000 Lille, France
| | - J Girard
- Université Lille Nord de France, 59000 Lille, France; Département de médecine du sport, faculté de médecine de Lille, université de Lille 2, Lille, France; Service d'orthopédie C, hôpital Salengro, place de Verdun, CHU de Lille, 59000 Lille, France.
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18
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Sergeev ME, Morgia F, Lazari M, Wang C, van Dam RM. Titania-catalyzed radiofluorination of tosylated precursors in highly aqueous medium. J Am Chem Soc 2015; 137:5686-94. [PMID: 25860121 DOI: 10.1021/jacs.5b02659] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Nucleophilic radiofluorination is an efficient synthetic route to many positron-emission tomography (PET) probes, but removal of water to activate the cyclotron-produced [(18)F]fluoride has to be performed prior to reaction, which significantly increases overall radiolabeling time and causes radioactivity loss. In this report, we demonstrate the possibility of (18)F-radiofluorination in highly aqueous medium. The method utilizes titania nanoparticles, 1:1 (v/v) acetonitrile-thexyl alcohol solvent mixture, and tetra-n-butylammonium bicarbonate as a phase-transfer agent. Efficient radiolabeling is directly performed with aqueous [(18)F]fluoride without the need for a drying/azeotroping step to significantly reduce radiosynthesis time. High radiochemical purity of the target compound is also achieved. The substrate scope of the synthetic strategy is demonstrated with a range of aromatic, aliphatic, and cycloaliphatic tosylated precursors.
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Affiliation(s)
- Maxim E Sergeev
- Department of Molecular and Medical Pharmacology and Crump Institute for Molecular Imaging, David Geffen School of Medicine at University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, California 90095, United States
| | - Federica Morgia
- Department of Molecular and Medical Pharmacology and Crump Institute for Molecular Imaging, David Geffen School of Medicine at University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, California 90095, United States
| | - Mark Lazari
- Department of Molecular and Medical Pharmacology and Crump Institute for Molecular Imaging, David Geffen School of Medicine at University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, California 90095, United States
| | - Christopher Wang
- Department of Molecular and Medical Pharmacology and Crump Institute for Molecular Imaging, David Geffen School of Medicine at University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, California 90095, United States
| | - R Michael van Dam
- Department of Molecular and Medical Pharmacology and Crump Institute for Molecular Imaging, David Geffen School of Medicine at University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, California 90095, United States
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Zheng G, Zhong H, Guo Z, Wu Z, Zhang H, Wang C, Zhou Y, Zuo Z. Levels of heavy metals and trace elements in umbilical cord blood and the risk of adverse pregnancy outcomes: a population-based study. Biol Trace Elem Res 2014; 160:437-44. [PMID: 25008990 DOI: 10.1007/s12011-014-0057-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 06/18/2014] [Indexed: 01/17/2023]
Abstract
To better understand the relationship between prenatal exposure to heavy metals and trace elements and the risk of adverse pregnancy outcomes, we investigated the status of heavy metals and trace elements level in a Chinese population by collecting umbilical cord blood. Umbilical cord blood heavy metals and trace elements concentrations were determined by inductively coupled plasma-mass spectrometry. No differences with statistical significance in the median arsenic (As), cadmium (Cd), cobalt (Co), chromium (Cr), copper (Cu), manganese (Mn), nickel (Ni), lead (Pb), strontium (Sr), thallium (Tl), vanadium (V), and zinc (Zn) concentrations were observed between the adverse pregnancy outcome group and the reference group. Titanium (Ti) and antimony (Sb) were found at higher levels with statistical significance in the cord blood samples with adverse pregnancy group when compared to the ones in the reference group. The association between Ti levels and the risk of adverse pregnancy outcomes remained significant after adjusting for potential confounding factors, including newborn weight. These results indicated that environmental exposure to Ti may increase the risk of adverse pregnancy outcomes in Chinese women without occupational exposure.
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Affiliation(s)
- Guanchao Zheng
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, Xiamen University, Xiamen, 361102, China
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