1
|
Sheridan GA, Neufeld ME, Sidhu A, Kurmis AP, Kelly M, O'Byrne JM, Howard LC, Masri BA, Garbuz DS. The Diagnostic Utility of Serum Metal Ion Markers for High-Grade Aseptic Lymphocyte-Dominated Vasculitis-Associated Lesions (ALVALs) in Revision Hip and Knee Arthroplasty: An International Multicenter Study. J Arthroplasty 2024; 39:206-210. [PMID: 37331438 DOI: 10.1016/j.arth.2023.06.024] [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: 01/22/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Aseptic lymphocyte-dominated vasculitis-associated lesions (ALVALs) are typically described in the context of metal-on-metal (MoM) hip bearings. This study explores the diagnostic utility of preoperative serum cobalt and chromium ion levels in determining the histological grade of ALVAL in revision hip and knee arthroplasty. METHODS This was a multicenter retrospective review of 26 hips and 13 knees assessing the correlation between preoperative ion levels (mg/L (ppb)) and the histological grade of ALVAL from intraoperative specimens. The diagnostic ability of preoperative serum cobalt and chromium levels to determine high-grade ALVAL was assessed using a receiver operating characteristic (ROC) curve. RESULTS In the knee cohort, there was a higher serum cobalt level in high-grade ALVAL cases (10.2 mg/L (ppb) versus 3.1 mg/L (ppb)) (P = .0002). The Area Under the Curve (AUC) was 1.00 (95% confidence interval (CI) 1.00 to 1.00). There was a higher serum chromium level in high-grade ALVAL cases (12.25 mg/L (ppb) versus 7.77 mg/L (ppb)) (P = .0002). The AUC was 0.806 (95% CI 0.555 to 1.00). In the hip cohort, there was a higher serum cobalt level in high-grade ALVAL cases (333.5 mg/L (ppb) versus 119.9 mg/L (ppb)) (P = .0831). The AUC was 0.619 (95% CI 0.388 to 0.849). There was a higher serum chromium level in high-grade ALVAL cases (186.4 mg/L (ppb) versus 79.3 mg/L (ppb)) (P = .183). The AUC was 0.595 (95% CI 0.365 to 0.824). CONCLUSIONS Histologically, high-grade ALVAL has significantly higher preoperative serum cobalt and chromium ion levels in revision TKA. Preoperative serum ion levels have excellent diagnostic utility in revision TKA. Cobalt levels in revision THA have a fair diagnostic ability and chromium levels had a poor diagnostic ability.
Collapse
Affiliation(s)
- Gerard A Sheridan
- Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Michael E Neufeld
- Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Arsh Sidhu
- Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Andrew P Kurmis
- Department of Orthopaedic Surgery, Lyell McEwin Hospital, Vale, Elizabeth, SA, Australia
| | - Martin Kelly
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Lisa C Howard
- Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Donald S Garbuz
- Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| |
Collapse
|
2
|
The Induced Pluripotent Stem Cells in Articular Cartilage Regeneration and Disease Modelling: Are We Ready for Their Clinical Use? Cells 2022; 11:cells11030529. [PMID: 35159338 PMCID: PMC8834349 DOI: 10.3390/cells11030529] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 02/01/2023] Open
Abstract
The development of induced pluripotent stem cells has brought unlimited possibilities to the field of regenerative medicine. This could be ideal for treating osteoarthritis and other skeletal diseases, because the current procedures tend to be short-term solutions. The usage of induced pluripotent stem cells in the cell-based regeneration of cartilage damages could replace or improve on the current techniques. The patient’s specific non-invasive collection of tissue for reprogramming purposes could also create a platform for drug screening and disease modelling for an overview of distinct skeletal abnormalities. In this review, we seek to summarise the latest achievements in the chondrogenic differentiation of pluripotent stem cells for regenerative purposes and disease modelling.
Collapse
|
3
|
Houdek MT, Taunton MJ, Wyles CC, Jannetto PJ, Lewallen DG, Berry DJ. Synovial Fluid Metal Ion Levels are Superior to Blood Metal Ion Levels in Predicting an Adverse Local Tissue Reaction in Failed Total Hip Arthroplasty. J Arthroplasty 2021; 36:3312-3317.e1. [PMID: 34030874 PMCID: PMC9376798 DOI: 10.1016/j.arth.2021.04.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/21/2021] [Accepted: 04/26/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Adverse local tissue reactions (ALTR) are associated with total hip arthroplasty (THA) failure in patients with metal-on-metal bearings and/or taper corrosion, which can also occur in metal-on-polyethylene articulations. Patients are monitored with blood cobalt (Co) and chromium (Cr) concentrations which do not always correlate with the degree of soft tissue reaction at revision THA. The purpose of this study was to determine how the blood and prosthetic hip synovial fluid levels of Co and Cr correlate with one another, and determine which concentration is more predictive of ALTR. METHODS Synovial fluid and blood samples were collected at the time of revision THA in patients with (n = 26) and without ALTR (n = 27). Whole blood, serum, and synovial fluid metal ion concentrations were correlated with one another and clinical findings. RESULTS The ratio of synovial fluid to whole blood Co concentration in ALTR and non-ALTR hips was 120:1 and 18:1 (P = .006). The mean ratio of synovial fluid to whole blood Cr concentration in ALTR and non-ALTR hips was 414:1 and 24:1 (P = .01). The mean synovial fluid Co/Cr concentrations were elevated in patients with ALTR compared with those without (2007.3 vs. 12.4 ppb, P = .007) and (3188.2 vs. 10.3 ppb, P = .02). The synovial fluid Co concentration was the most accurate test for detecting ALTR (cut off: 19.75 PPB, AUC 0.973). CONCLUSION In patients with ALTR, synovial fluid Co and Cr levels were 120 times higher and 414 times higher than whole blood Co and Cr levels. Synovial fluid Co ion concentration was the most accurate in predicting ALTR. LEVEL OF EVIDENCE Diagnostic level II.
Collapse
Affiliation(s)
- Matthew T. Houdek
- Mayo Clinic, Department of Orthopedic Surgery, 200 First St. SW, Rochester, MN 55905
| | - Michael J. Taunton
- Mayo Clinic, Department of Orthopedic Surgery, 200 First St. SW, Rochester, MN 55905
| | - Cody C. Wyles
- Mayo Clinic, Department of Orthopedic Surgery, 200 First St. SW, Rochester, MN 55905
| | - Paul J. Jannetto
- Mayo Clinic, Department of Laboratory Medicine and Pathology, 200 First St. SW, Rochester, MN 55905
| | - David G. Lewallen
- Mayo Clinic, Department of Orthopedic Surgery, 200 First St. SW, Rochester, MN 55905
| | - Daniel J. Berry
- Mayo Clinic, Department of Orthopedic Surgery, 200 First St. SW, Rochester, MN 55905,Corresponding Author: Correspondence: Daniel J. Berry, M.D., Mayo Clinic, Department of Orthopedic Surgery, 200 First St. SW, Rochester, MN 55905, Telephone Number: 507-284-8314,
| |
Collapse
|
4
|
Sub-toxic levels of Co 2+ are anti-inflammatory and protect cartilage from degradation caused by IL-1β. Clin Biomech (Bristol, Avon) 2020; 79:104924. [PMID: 31928794 DOI: 10.1016/j.clinbiomech.2019.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 11/23/2019] [Accepted: 12/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cobalt ions from some orthopaedic implants induce a dose-dependent cytotoxic and pro-inflammatory response. Recent studies show that sub-toxic levels of cobalt influence actin organisation regulating fibroblasts and macrophages behaviour. However little is known about the influence of sub-toxic levels of cobalt on articular cartilage biology and biomechanics. Previously, we have reported that IL-1β signalling in chondrocytes, is regulated by primary cilia and associated intraflagellar transport. Since primary cilia expression is modulated by actin organisation, we set out to test the hypothesis that sub-toxic levels of cobalt regulate cilia expression and IL-1β signalling thereby influencing articular cartilage degradation. METHODS Isolated chondrocytes and bovine cartilage explants were subjected to Co2+ in the presence and absence of IL-1β. Primary cilia were monitored by confocal immunofluorescence. Nitric oxide and PGE2 release were used to monitor IL-1β signalling. Degradation of cartilage matrix was assessed by the release of sGAG and the biomechanical properties of the tissue in uniaxial unconfined compression. FINDINGS Sub-toxic levels of Co2+ (50 μM) blocked IL-1β-induced primary cilia elongation in isolated chondrocytes. This was associated with disruption of pro-inflammatory signalling in both isolated chondrocytes and cartilage explants, and inhibition of cartilage matrix degradation and loss of biomechanical properties. INTERPRETATION This study reveals that low levels of cobalt ions are anti-inflammatory, preventing cartilage degradation in response to IL-1β. This mechanism is associated with regulation of primary cilia elongation. These observations provide new insight into the potential beneficial role of cobalt and may lead to novel mechanisms for controlling cartilage inflammation.
Collapse
|
5
|
Nousiainen T, Palosaari S, Peräniemi S, Tervahauta A, Niinimäki J, Leppilahti J, Lehenkari P. Retention of metals in periprosthetic tissues of patients with metal-on-metal total hip arthroplasty is reflected in the synovial fluid to blood cobalt transfer ratio in the presence of a pseudotumour. BMC Musculoskelet Disord 2020; 21:610. [PMID: 32919463 PMCID: PMC7488743 DOI: 10.1186/s12891-020-03636-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 09/07/2020] [Indexed: 02/08/2023] Open
Abstract
Background Modern metal-on-metal (MOM) arthroplasties were performed for over a decade before alarming reports of adverse metal reactions dramatically reduced their use. Failures are seen more often with high-wearing implants, but also well-positioned components with more favourable wear patterns can cause problems. There are no specific clinical indicators that could help us to predict the prognosis of these implants. For this reason, we still need more information on the effect of underlying factors that contribute to this process. Methods In this prospective cohort study, we investigated how cup orientation and type of pseudotumour determined by the Hart classification effect the distribution of metals in blood, synovial fluid and tissues surrounding the metal-on-metal hip prosthesis in revision surgery patients. One thousand two hundred twenty-nine metal-on-metal hip patients were screened and of those, 60 patients that had a revision surgery due to adverse metal reaction were included. Whole blood, synovial fluid and synovial/pseudotumour tissue samples were analysed for metal ion concentrations (Co, Cr, Mo and Ti). Results The lowest metal concentrations were found when both cup anteversion and inclination were optimal, and the highest when both were suboptimal. Suboptimal anteversion alone raised Cr-ion concentrations more than suboptimal inclination. The concentrations of metals in blood, synovial fluid or synovial soft tissue were the same in patients with and without a pseudotumour, but the relative transfer percentage of cobalt from synovial fluid to blood was higher in patients with a pseudotumour. Conclusions The implant orientation alone does not explain the metal concentrations found in tissues or distribution of metals between different tissues. The accumulation of metals in periprosthetic soft tissues increase the total metal load, and in the presence of a pseudotumour this is reflected in the transfer ratio of Co from synovial fluid to the blood. The total metal load of the pseudotumour tissue should be defined in future studies to determine if this will provide new insights for clinical practice.
Collapse
Affiliation(s)
- Tomi Nousiainen
- Medical Faculty, Cancer and Translational Medicine Research Unit, University of Oulu and Medical Research Center, Oulu University Hospital, P.O. Box 5000, 90014, Oulu, Finland. .,Division of Orthopaedic Surgery, Oulu University Hospital, Oulu, Finland.
| | - Sanna Palosaari
- Medical Faculty, Cancer and Translational Medicine Research Unit, University of Oulu and Medical Research Center, Oulu University Hospital, P.O. Box 5000, 90014, Oulu, Finland
| | - Sirpa Peräniemi
- University of Eastern Finland, School of Pharmacy, P.O. Box 1627, 70210, Kuopio, Finland
| | - Arja Tervahauta
- Department of Environmental and Biological Sciences, University of Eastern Finland, P.O. Box 1627, 70210, Kuopio, Finland
| | | | - Juhana Leppilahti
- Division of Orthopaedic Surgery, Oulu University Hospital, Oulu, Finland
| | - Petri Lehenkari
- Medical Faculty, Cancer and Translational Medicine Research Unit, University of Oulu and Medical Research Center, Oulu University Hospital, P.O. Box 5000, 90014, Oulu, Finland.,Division of Orthopaedic Surgery, Oulu University Hospital, Oulu, Finland
| |
Collapse
|
6
|
Wiegand MJ, Khullar P, Mercuri JJ, Gilbert JL. Synthetic periprosthetic synovial fluid development for in vitro cell-tribocorrosion testing using the Taguchi array approach. J Biomed Mater Res A 2020; 109:551-561. [PMID: 32946189 DOI: 10.1002/jbm.a.37039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/04/2020] [Accepted: 06/09/2020] [Indexed: 12/26/2022]
Abstract
Synovial fluid is dynamic in vivo with biological components changing in ratio and size depending on the health of the joint space, making it difficult to model in vitro. Previous efforts to develop synthetic synovial fluid have typically focused on single organic-tribological interactions with implant surfaces, thus ignoring interplay between multiple solution components. Using a Taguchi orthogonal array, we were able to isolate the individual effects of five independent synovial fluid composition variables: ratios of (1) hyaluronic acid to phospholipids (HA:PL) and (2) albumin to globulin (A:G), and concentrations of (3) hydrogen peroxide (H2 O2 ), (4) cobalt (Co2+ ) and (5) chromium (Cr3+ ) ions on macrophage viability and reduced glutathione production, local solution pH and the comprehensive CoCrMo alloy electrochemical response. While no single synovial fluid variable significantly affected the collective response, HA:PL ratio resulted in the largest impact factor (Δ) on 12 of the 13 measured responses with significant effects (p < .05) on the average macrophage survival rate and electrochemical capacitive state of the CoCrMo surface. Cluster analysis separated significant responses from all trials into three groups, corresponding to healthy, mild, or severely inflamed fluids, respectively; with the healthy synovial fluid composition having mid-range HA:PL ratios with no Co2+ ions, and the severely inflamed fluids consisting of low and high HA:PL ratios with H2 O2 and Co2+ ions. By utilizing the Taguchi approach in combination with cluster analysis, we were able to advance our knowledge of complex multivariate synthetic synovial fluids influence on macrophage and electrochemical behavior at the cell-solution-metal interface.
Collapse
Affiliation(s)
- Michael J Wiegand
- Department of Bioengineering, Clemson University, Clemson, South Carolina, USA.,The Clemson University-Medical University of South Carolina Program in Bioengineering, Clemson University, Charleston, South Carolina, USA
| | - Piyush Khullar
- Department of Bioengineering, Clemson University, Clemson, South Carolina, USA.,The Clemson University-Medical University of South Carolina Program in Bioengineering, Clemson University, Charleston, South Carolina, USA
| | - Jeremy J Mercuri
- Department of Bioengineering, Clemson University, Clemson, South Carolina, USA
| | - Jeremy L Gilbert
- Department of Bioengineering, Clemson University, Clemson, South Carolina, USA.,The Clemson University-Medical University of South Carolina Program in Bioengineering, Clemson University, Charleston, South Carolina, USA
| |
Collapse
|
7
|
Carulli C, Sani G, Matassi F, Civinini R, Innocenti M. A Mid- to Long-Term Follow-Up Experience with a Specific Metal-on-Metal Total Hip Arthroplasty Design. JOINTS 2020; 7:91-97. [PMID: 34195536 PMCID: PMC8236331 DOI: 10.1055/s-0040-1710388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 04/04/2020] [Indexed: 11/09/2022]
Abstract
Purrpose
Metal-on-metal (MoM) total hip arthroplasty (THA) has been a subject of recent discussion and concern due to the early failures caused by local and systemic adverse reactions related to specific designs. The aim of this study is to analyze the outcomes and survival rates of a single brand of MoM implants implanted in a consecutive series of patients at a single institution.
Methods
Between 2007 and 2012, 116 (118 hips) patients were evaluated at a mean follow-up of 6.6 years after primary THA. The diagnosis leading to surgery was osteoarthritis (80 patients) and proximal femoral fracture (36 patients). A single design of THA was implanted. All patients were evaluated before surgery and postoperatively at 1, 3, 6, and 12 months by clinical scores and radiographic studies. The data analysis was made using Student's
t
-test.
Results
The minimum follow-up was of 4 years, with a mean follow-up of 6.6 years. Two aseptic loosenings of the acetabular component were recorded (one per group), which were not associated with local or systemic complications related to metal ion release. Both were revised by an isolated acetabular cup substitution with metal-on-polyethylene couplings. Nonprogressive radiolucency lines < 2 mm in zone 2 were observed in other six patients around the acetabular component without clinical manifestation (four in the arthritis group and two in the fracture group). Postoperative Harris Hip Score and SF-36 (36-Item Short Form Survey) score improved in both groups.
Conclusion
Despite several MoM implants showing early complications and failures, a specific MoM design may be associated with good clinical results at a mid- to long-term follow-up.
Level of Evidence
This is a therapeutic case series, Level 4 study.
Collapse
Affiliation(s)
| | - Giacomo Sani
- Orthopaedic Clinic, University of Florence, Florence, Italy
| | | | | | | |
Collapse
|
8
|
D'Ambrosi R, Ursino N. N-Acetyl-Cysteine Reduces Blood Chromium and Cobalt Levels in Metal-on-Metal Hip Arthroplasty. Arthroplast Today 2020; 6:149-152. [PMID: 32346587 PMCID: PMC7183002 DOI: 10.1016/j.artd.2020.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/11/2020] [Accepted: 03/14/2020] [Indexed: 11/27/2022] Open
Abstract
The most common reasons for revision of metal-on-metal hip arthroplasty are aseptic loosening and metal reaction. Failure of a metal-on-metal implant due to the aggressive destruction of periprosthetic tissues may require extensive reconstruction procedures. The aim of this case report is to describe the treatment in an asymptomatic patient with high levels of chromium and cobalt, using chelation therapy. The rational use of N-acetyl-cysteine (NAC) involves thiol groups to chelate sites for metals. More than 10 years after the metal-on-metal hip arthroplasty, the patient did not have to undergo revision surgery; the levels of the ions in the blood were considerably lowered (chromium from 4.51 mcg/L to 1.85 mcg/L; cobalt from 7.78 UG/L to 0.8 UG/L) after using NAC without adverse effects.
Collapse
|
9
|
Lehtovirta L, Reito A, Lainiala O, Parkkinen J, Hothi H, Henckel J, Hart A, Eskelinen A. Host-specific factors affect the pathogenesis of adverse reaction to metal debris. BMC Musculoskelet Disord 2019; 20:195. [PMID: 31054584 PMCID: PMC6499989 DOI: 10.1186/s12891-019-2578-0] [Citation(s) in RCA: 5] [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: 04/02/2019] [Accepted: 04/16/2019] [Indexed: 02/08/2023] Open
Abstract
Background Adverse Reaction to Metal Debris (ARMD) is a major reason for revision surgeries in patients with metal-on-metal (MoM) hip replacements. Most failures are related to excessively wearing implant producing harmful metal debris (extrinsic factor). As ARMD may also occur in patients with low-wearing implants, it has been suggested that there are differences in host-specific intrinsic factors contributing to the development of ARMD. However, there are no studies that have directly assessed whether the development of ARMD is actually affected by these intrinsic factors. Methods We included all 29 patients (out of 33 patients) with sufficient data who had undergone bilateral revision of ASR MoM hips (58 hips) at our institution. Samples of the inflamed synovia and/or pseudotumour were obtained perioperatively and sent to histopathological analysis. Total wear volumes of the implants were assessed. Patients underwent MARS-MRI imaging of the hips preoperatively. Histological findings, imaging findings and total wear volumes between the hips of each patient were compared. Results The difference in wear volume between the hips was clinically and statistically significant (median difference 15.35 mm3, range 1 to 39 mm3, IQR 6 to 23 mm3) (p < 0.001). The median ratio of total wear volume between the hips was 2.0 (range 1.09 to 10.0, IQR 1.67 to 3.72). In majority of the histological features and in presence of pseudotumour, there were no differences between the left and right hip of each patient (p > 0.05 for all comparisons). These features included macrophage sheet thickness, perivascular lymphocyte cuff thickness, presence of plasma cells, presence of diffuse lymphocytic infiltration and presence of germinal centers. Conclusions Despite the significantly differing amounts of wear (extrinsic factor) seen between the sides, majority of the histological findings were similar in both hips and the presence of pseudotumour was symmetrical in most hips. As a direct consequence, it follows that there must be intrinsic factors which contribute to the symmetry of the findings, ie. the pathogenesis of ARMD, on individual level. This has been hypothesized in the literature but no studies have been conducted to confirm the hypothesis. Further, as the threshold of metal debris needed to develop ARMD appears to be largely variable based on the previous literature, it is likely that there are between-patient differences in these intrinsic factors, ie. the host response to metal debris is individual. Electronic supplementary material The online version of this article (10.1186/s12891-019-2578-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Lari Lehtovirta
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland.,Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | | | | | | | | |
Collapse
|
10
|
Connelly JW, Galea VP, Laaksonen I, Matuszak SJ, Madanat R, Muratoglu O, Malchau H. Indications for MARS-MRI in Patients Treated With Articular Surface Replacement XL Total Hip Arthroplasty. J Arthroplasty 2018; 33:2906-2911. [PMID: 29776852 DOI: 10.1016/j.arth.2018.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to identify which patient and clinical factors are predictive of adverse local tissue reaction (ALTR) and to use these factors to create a highly sensitive algorithm for indicating metal artifact reduction sequence magnetic resonance imaging (MARS-MRI) in Articular Surface Replacement (ASR) XL total hip arthroplasty patients. Our secondary aim was to compare our algorithm to existing national guidelines on when to take MARS-MRI in metal-on-metal total hip arthroplasty patients. METHODS The study consisted of 137 patients treated with unilateral ASR XL implants from a prospective, multicenter study. Patients underwent MARS-MRI regardless of clinical presentation at a mean of 6.2 (range, 3.3-10.4) years from surgery. Univariate and multivariate analyses were conducted to determine which variables were predictive of ALTR. Predictors were used to create an algorithm to indicate MARS-MRI. Finally, we compared our algorithm's ability to detect ALTR to existing guidelines. RESULTS We found a visual analog scale pain score ≥2 (odds ratio [OR] = 2.53; P = .023), high blood cobalt (OR = 1.05; P = .023), and male gender (OR = 2.37; P = .034) to be significant predictors of ALTR presence in our cohort. The resultant algorithm achieved 86.4% sensitivity and 60.2% specificity in detecting ALTR within our cohort. Our algorithm had the highest area under the curve and was the only guideline that was significantly predictive of ALTR (P = .014). CONCLUSION Our algorithm including patient-reported pain and sex-specific cutoffs for blood cobalt levels could predict ALTR and indicate MARS-MRI in our cohort of ASR XL metal-on-metal patients with high sensitivity. LEVEL OF EVIDENCE Level II, diagnostic study.
Collapse
Affiliation(s)
- James W Connelly
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Vincent P Galea
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Inari Laaksonen
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Sean J Matuszak
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Rami Madanat
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Orhun Muratoglu
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Henrik Malchau
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
11
|
Lehtovirta L, Reito A, Parkkinen J, Peräniemi S, Vepsäläinen J, Eskelinen A. Association between periprosthetic tissue metal content, whole blood and synovial fluid metal ion levels and histopathological findings in patients with failed metal-on-metal hip replacement. PLoS One 2018; 13:e0197614. [PMID: 29768492 PMCID: PMC5955572 DOI: 10.1371/journal.pone.0197614] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 05/04/2018] [Indexed: 02/08/2023] Open
Abstract
Adverse Reaction to Metal Debris (ARMD) is a major cause of implant failure leading to revision surgery in patients with metal-on-metal (MoM) hip arthroplasties. However, the pathogenesis and its association to implant wear are poorly understood and previous studies have yielded discrepant results. We sought to investigate the associations between histological findings, whole blood and synovial fluid metal ion concentrations and periprosthetic tissue metal concentrations in patients with MoM total hip replacements and hip resurfacings revised for ARMD. 107 hips in total were included in our study. Of these, 87 were total hip replacements and 20 were hip resurfacings, respectively. We found that whole blood, synovial fluid and periprosthetic tissue metal concentrations correlated poorly with histological findings. We suggest that the lack of a clear association between histological findings and wear measures in the present study as well as in previous studies is mostly influenced by variability in patient susceptibility. However, patients presenting with perivascular lymphocytic infiltration had lower chromium concentration in their periprosthetic tissues than patients with no perivascular lymphocytic infiltration. This may reflect the role of metal hypersensitivity in implant failure in these patients. Patients with total hip replacements evinced more necrosis and lymphocytic infiltration in their tissues than patients with hip resurfacings. This suggests that trunnion wear debris is more cytotoxic and/or immunogenic than bearing wear debris leading to higher failure rates seen in patients with total hip replacements.
Collapse
Affiliation(s)
- Lari Lehtovirta
- University of Tampere, Tampere, Finland
- Coxa Hospital for Joint Replacement, Tampere, Finland
- * E-mail:
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | | | | | | |
Collapse
|
12
|
Lehtovirta L, Reito A, Parkkinen J, Hothi H, Henckel J, Hart A, Eskelinen A. Analysis of bearing wear, whole blood and synovial fluid metal ion concentrations and histopathological findings in patients with failed ASR hip resurfacings. BMC Musculoskelet Disord 2017; 18:523. [PMID: 29228956 PMCID: PMC5725985 DOI: 10.1186/s12891-017-1894-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 12/04/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Adverse Reaction to Metal Debris (ARMD) is still a major reason for revision surgeries in patients with metal-on-metal (MoM) hip replacements. ARMD consists of a wide range of alterations in periprosthetic tissues, most important of which are metallosis, inflammation, pseudotumors and necrosis. Studies investigating histopathological findings and their association to implant wear or indirect measures of wear have yielded inconsistent results. Therefore, we aimed to investigate bearing surface wear volume, whole blood and synovial fluid metal ion concentrations, histopathological findings in periprosthetic tissues and their associations. METHODS Seventy-eight patients with 85 hips revised for ARMD were included in the study. Prior to revision surgery, all patients had whole blood chromium and cobalt ion levels assessed. In revision surgery, a synovial fluid sample was taken and analyzed for chromium and cobalt. Periprosthetic tissue samples were taken and analyzed for histopathological findings. Explanted implants were analyzed for bearing wear volume of both acetabular cup and femoral head components. RESULTS Volumetric wear of the failed components was highly variable. The total wear volume of the head and cup had a strong correlation with whole blood chromium and cobalt ion concentrations (Cr: ρ = 0.80, p < 0.001 and Co: ρ = 0.84, p < 0.001) and a bit weaker correlation with fluid chromium and cobalt ion concentrations (Cr: ρ = 0.50, p < 0.01 and Co: ρ = 0.41, p = 0.027). Most tissues displayed only low-to-moderate amounts of macrophages and lymphocytes. Total wear volume correlated with macrophage sheet thickness (ρ = 0.25, p = 0.020) and necrosis (ρ = 0.35, p < 0.01). Whole blood chromium and cobalt ion concentrations had similar correlations. Lymphocyte cuff thickness did not correlate with either total wear volume or whole blood metal ion concentrations, but correlated with the grade of necrosis. CONCLUSIONS Bearing wear volume correlated with blood metal ion levels and the degree of necrosis and macrophage infiltration in periprosthetic tissues suggesting a dose-response relationship. Whole blood metal ion levels are a useful tool for clinician to estimate bearing wear and subsequent tissue response.
Collapse
Affiliation(s)
- Lari Lehtovirta
- Faculty of Medicine, University of Tampere, Tampere, Finland
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | | | | | | | | |
Collapse
|
13
|
Current Pathologic Scoring Systems for Metal-on-metal THA Revisions are not Reproducible. Clin Orthop Relat Res 2017; 475:3005-3011. [PMID: 28688018 PMCID: PMC5670057 DOI: 10.1007/s11999-017-5432-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 06/23/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aseptic lymphocyte vasculitis-associated lesion (ALVAL) score and the modified Oxford ALVAL score are frequently used scoring methods to evaluate the morphologic features of periprosthetic tissues around metal-on-metal (MoM) hip implants. Except for the initial studies of these two morphology scoring methods, to our knowledge, no other studies have reported on intraclass correlation coefficient (ICC) values for interobserver reliability of these scoring methods. QUESTIONS/PURPOSES Are the ALVAL and Oxford ALVAL scores reproducible? METHODS The periprosthetic tissue of 37 revisions of 36 patients with failed MoM THAs were independently scored by three experienced pathologists using ALVAL and Oxford ALVAL scoring methods. All patients were included who underwent revision surgery in our hospital until January 2013, with a large-head MoM prosthesis and also met the criteria: blood serum cobalt levels, available MRI scan, and intraarticular cobalt levels. The population included 26 patients with pseudotumors diagnosed by two radiologists using the method described by Matthies et al. The ALVAL describes morphologic features of the synovial lining, tissue organization, and inflammatory cell infiltrate in periprosthetic tissues. The Oxford-ALVAL score uses a semiquantitative measure of the immune response which should be easier to score. RESULTS The ALVAL score showed an ICC of 0.38 (95% CI, 0.18-0.58) (fair) for the sum score and this improved up to 0.50 (95% CI, 0.31-0.68) (moderate) using the modified Oxford ALVAL score. The individual parameters of the ALVAL score showed an ICC for the scoring of inflammatory infiltrate of 0.37 (95% CI, 0.17-0.57), an ICC of 0.32 (95% CI, 0.12-0.53) for the scoring of tissue organization, and an ICC of 0.14 (95% CI, -0.04 to 0.34) for synovial lining. CONCLUSIONS Scoring morphologic features of MoM tissue is not reproducible using the ALVAL score or the Oxford ALVAL score. This may reflect heterogeneous morphologic features in tumor tissue and between different tumor tissue samples that cannot be reliably quantified by pathologists using the parameters of these two scoring methods. An alternative, simplified scoring system should be developed to improve the interrater agreement. LEVEL OF EVIDENCE Level III, diagnostic study.
Collapse
|
14
|
McGrory BJ, Jorgensen AH. High Early Major Complication Rate After Revision for Mechanically Assisted Crevice Corrosion in Metal-on-Polyethylene Total Hip Arthroplasty. J Arthroplasty 2017; 32:3704-3710. [PMID: 28781018 DOI: 10.1016/j.arth.2017.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/14/2017] [Accepted: 07/06/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Failed total hip arthroplasty caused by mechanically assisted crevice corrosion (MACC) has serious consequences such as adverse local tissue reaction. Revision is currently indicated for significant hip pain, stiffness, and dysfunction; hip instability; progressive bone loss; and soft tissue destruction. Outcomes of this revision surgery are not yet completely understood. METHODS We examined the surgical outcomes at a minimum of 6 months (average, 25; range, 7-68 months) in a cohort of 27 consecutive patients who underwent revision total hip arthroplasty for MACC associated with a single implant vendor and taper type. RESULTS Major orthopedic complications occurred in 7 of 27 patients (25.9%), each after the original revision surgery. Five additional major complications occurred in subsequent surgeries. Postoperative hip dislocation occurred in 6 of 27 (22.2%), deep infection occurred in 3 of 27 (11.1%), and aseptic acetabular loosening, seroma requiring irrigation and debridement, pulmonary embolism, periprosthetic fracture, and reintubation each occurred in 1 of 27 (3.7%). Harris hip scores improved significantly with surgery (P = .0002), but overall, scores were lower for those who had major complications (70.9 vs 89.2), and only 20 of 27 patients (74.1%) had good or excellent outcomes. CONCLUSION Symptomatic MACC is a potentially devastating diagnosis, because of decreased soft tissue and bone viability associated with adverse local tissue reaction. This leads to a high early major complication rate.
Collapse
Affiliation(s)
- Brian J McGrory
- Tufts University School of Medicine, Boston, Massachusetts; Maine Joint Replacement Institute, Portland, Maine; Maine Medical Center Division of Joint Replacements, Falmouth, Maine
| | | |
Collapse
|
15
|
Abstract
Allergic or hypersensitivity reactions to orthopaedic implants can pose diagnostic and therapeutic challenges. Although 10% to 15% of the population exhibits cutaneous sensitivity to metals, deep-tissue reactions to metal implants are comparatively rare. Nevertheless, the link between cutaneous sensitivity and clinically relevant deep-tissue reactions is unclear. Most reactions to orthopaedic devices are type IV, or delayed-type hypersensitivity reactions. The most commonly implicated allergens are nickel, cobalt, and chromium; however, reactions to nonmetal compounds, such as polymethyl methacrylate, antibiotic spacers, and suture materials, have also been reported. Symptoms of hypersensitivity to implants are nonspecific and include pain, swelling, stiffness, and localized skin reactions. Following arthroplasty, internal fixation, or implantation of similarly allergenic devices, the persistence or early reappearance of inflammatory symptoms should raise suspicions for hypersensitivity. However, hypersensitivity is a diagnosis of exclusion. Infection, as well as aseptic loosening, particulate synovitis, instability, and other causes of failure must first be eliminated.
Collapse
|
16
|
McGrory BJ, Payson AM, MacKenzie JA. Elevated Intra-Articular Cobalt and Chromium Levels in Mechanically Assisted Crevice Corrosion in Metal-on-Polyethylene Total Hip Arthroplasty. J Arthroplasty 2017; 32:1654-1658. [PMID: 28041772 DOI: 10.1016/j.arth.2016.11.056] [Citation(s) in RCA: 28] [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: 10/05/2016] [Revised: 11/14/2016] [Accepted: 11/29/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Failed total hip arthroplasty (THA) caused by mechanically assisted crevice corrosion (MACC) has serious consequences such as adverse local tissue reaction (ALTR). Serum cobalt (Co) and chromium (Cr) ion levels have been used to diagnose taper corrosion, but have not been shown to be an accurate measure of the severity of MACC or associated ALTRs. Additionally, elevated serum ions are not specific in patients with multiple artificial joints. METHODS We examined the relationship between serum and intra-articular (IA) Co and Cr levels in a cohort of 20 patients undergoing revision THA, 16 who had symptomatic MACC. IA Co and Cr levels in MACC patients were compared with demographic, pre-operative, and operative findings. RESULTS Serum and IA metal levels were found to be relatively low in THA patients undergoing revision surgery for isolated instability, aseptic loosening, or infection (average serum Co 0.03 ppb [parts per billion], IA Co 1.4 ppb, serum Cr 0.32 ppb, IA Cr 3.3 ppb). In patients with MACC, average IA Co (940 ppb) was significantly higher than serum Co (5.1 ppb) (P = .0003) and IA Cr (491 ppb) was significantly higher than serum Cr (1.3 ppb) (P = .0003). IA Co level was associated with shorter time of hip symptoms to revision surgery (P = .0043). CONCLUSION Serum levels of Co and Cr correlated with joint levels in the entire cohort, but IA levels of MACC patients were 100 times greater than serum levels. IA Co and Cr levels may be useful in confirming MACC in a specific joint and the striking elevation may explain symptoms and ALTR with relatively low serum values.
Collapse
Affiliation(s)
- Brian J McGrory
- Tufts University School of Medicine, Boston, Massachusetts; Maine Joint Replacement Institute, Portland, Maine; Maine Medical Center Division of Joint Replacements, Falmouth, Maine
| | | | | |
Collapse
|
17
|
Maurer-Ertl W, Friesenbichler J, Holzer LA, Leitner L, Ogris K, Maier M, Leithner A. Recall of the ASR XL Head and Hip Resurfacing Systems. Orthopedics 2017; 40:e340-e347. [PMID: 27992643 DOI: 10.3928/01477447-20161213-04] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/31/2016] [Indexed: 02/03/2023]
Abstract
At the beginning of the 21st century, use of large-diameter, metal-on-metal devices was a popular procedure for hip replacement in young and physically active patients; however, within a few years, the number of revisions increased, resulting in a worldwide recall for the articular surface replacement (ASR) system. Complication rates for the ASR devices implanted at the authors' department are reported, with revision rates of 32% and 30% in the ASR XL Head and ASR Resurfacing groups, respectively. Reasons for revision surgery were serum metal ion elevation, luxation or subluxation, aseptic loosening, soft tissue compromise (adverse reactions to metal debris [ARMD]), and infection. The calculated implant survival for the ASR XL Head system and the ASR Resurfacing device (DePuy Orthopaedics Inc, Warsaw, Indiana) in the current series was 79% and 90%, respectively, at 60 months. Symptomatic patients with metal-on-metal devices, with or without elevated metal ion concentrations, should undergo cross sectional imaging to exclude ARMD. In cases of increased metal ion concentrations, local pain, or ARMD, revision surgery has to be evaluated. In the future, closer monitoring of new implants is needed to prevent high failure rates, as seen with the ASR design. Furthermore, the withdrawal of the device highlights the importance of national implant registries. [Orthopedics. 2017; 40(2):e340-e347.].
Collapse
|
18
|
Liow MHL, Kwon YM. Metal-on-metal total hip arthroplasty: risk factors for pseudotumours and clinical systematic evaluation. INTERNATIONAL ORTHOPAEDICS 2016; 41:885-892. [PMID: 27761629 DOI: 10.1007/s00264-016-3305-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/25/2016] [Indexed: 12/12/2022]
Abstract
The potential advantages of contemporary MoM THA implants include less volumetric wear with subsequent reduction of polyethylene wear-induced osteolysis and greater component stability with use of large-diameter femoral heads. However, there have been concerns regarding significantly elevated revision rates in MoM THA due to MoM-related complications such as adverse local tissue reaction (pseudotumour) formation. The increased failure rate in MoM hip arthroplasty is associated with the generation of biologically active, nanometer sized metal particles from the MoM bearing surfaces and taper junctions, which result in the development of a localized, adverse periprosthetic soft tissue response. The focus of this article is to provide an update on (1) implant, surgical and patient factors associated with adverse local tissue reactions (pseudotumours) and (2) the clinical systematic evaluation and management of patients with MoM hip arthroplasty based on the currently available evidence. There should be a low threshold to conduct a systematic clinical evaluation of patients with MoM hip arthroplasty as early recognition and diagnosis will allow the initiation of prompt and appropriate treatment. As a symptomatic MoM total hip arthroplasty may have intrinsic and extrinsic causes, patients should be evaluated systematically, utilizing risk stratification algorithms. Although specialized laboratory tests such as metal ion levels and cross sectional imaging modalities such as MARS MRI can be used to facilitate clinical decision making, over-reliance on any single investigative tool in the clinical decision-making process should be avoided. Further research is required to obtain a better understanding of implant and patient risk factors associated with tribocorrosion in MoM total hip arthroplasty.
Collapse
Affiliation(s)
- Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
19
|
A preliminary evaluation of immune stimulation following exposure to metal particles and ions using the mouse popliteal lymph node assay. Toxicol Appl Pharmacol 2016; 308:77-90. [DOI: 10.1016/j.taap.2016.07.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/17/2016] [Accepted: 07/26/2016] [Indexed: 01/22/2023]
|