1
|
Ude CC, Schmidt SJ, Laurencin S, Shah S, Esdaille J, Kan HM, Holt BD, Arnold AM, Wolf ME, Nair LS, Sydlik SA, Laurencin CT. Hyaluronic acid-British anti-Lewisite as a safer chelation therapy for the treatment of arthroplasty-related metallosis. Proc Natl Acad Sci U S A 2023; 120:e2309156120. [PMID: 37903261 PMCID: PMC10636327 DOI: 10.1073/pnas.2309156120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/17/2023] [Indexed: 11/01/2023] Open
Abstract
Cobalt-containing alloys are useful for orthopedic applications due to their low volumetric wear rates, corrosion resistance, high mechanical strength, hardness, and fatigue resistance. Unfortunately, these prosthetics release significant levels of cobalt ions, which was only discovered after their widespread implantation into patients requiring hip replacements. These cobalt ions can result in local toxic effects-including peri-implant toxicity, aseptic loosening, and pseudotumor-as well as systemic toxic effects-including neurological, cardiovascular, and endocrine disorders. Failing metal-on-metal (MoM) implants usually necessitate painful, risky, and costly revision surgeries. To treat metallosis arising from failing MoM implants, a synovial fluid-mimicking chelator was designed to remove these metal ions. Hyaluronic acid (HA), the major chemical component of synovial fluid, was functionalized with British anti-Lewisite (BAL) to create a chelator (BAL-HA). BAL-HA effectively binds cobalt and rescues in vitro cell vitality (up to 370% of cells exposed to IC50 levels of cobalt) and enhances the rate of clearance of cobalt in vivo (t1/2 from 48 h to 6 h). A metallosis model was also created to investigate our therapy. Results demonstrate that BAL-HA chelator system is biocompatible and capable of capturing significant amounts of cobalt ions from the hip joint within 30 min, with no risk of kidney failure. This chelation therapy has the potential to mitigate cobalt toxicity from failing MoM implants through noninvasive injections into the joint.
Collapse
Affiliation(s)
- Chinedu C. Ude
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Stephen J. Schmidt
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Samuel Laurencin
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Shiv Shah
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
- Department of Chemical and Biomolecular Engineering, University of Connecticut, Storrs, CT06269
| | - Jayson Esdaille
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Ho-Man Kan
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
| | - Brian D. Holt
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Anne M. Arnold
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Michelle E. Wolf
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
| | - Lakshmi S. Nair
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
- Department of Chemical and Biomolecular Engineering, University of Connecticut, Storrs, CT06269
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT06269
- Department of Materials Science and Engineering, University of Connecticut, Storrs, CT06269
- Institute of Materials Science, University of Connecticut, Storrs, CT06269
| | - Stefanie A. Sydlik
- Department of Chemistry, Carnegie Mellon University, Pittsburgh, PA15213
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA15213
| | - Cato T. Laurencin
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Farmington, CT06030
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT06030
- Department of Chemical and Biomolecular Engineering, University of Connecticut, Storrs, CT06269
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT06269
- Department of Materials Science and Engineering, University of Connecticut, Storrs, CT06269
- Institute of Materials Science, University of Connecticut, Storrs, CT06269
- Department of Craniofacial Sciences, School of Dental Medicine, University of Connecticut Health, Farmington, CT06030
| |
Collapse
|
2
|
He J, Li J, Wu S, Wang J, Tang Q. Accumulation of blood chromium and cobalt in the participants with metal objects: findings from the 2015 to 2018 National Health and Nutrition Examination Survey (NHANES). BMC Geriatr 2023; 23:72. [PMID: 36737686 PMCID: PMC9898935 DOI: 10.1186/s12877-022-03710-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 12/19/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Chromium (Cr) and cobalt (Co) are the essential elements for producing metal implants, but might have potential health issues. The research on the correlation between metal implants and blood Cr and Co on a large population is still limited. METHODS National Health and Nutrition Examination Survey (NHANES) is a program of studies designed to assess the health status of Americans began in the early 1960s. The study was based on the NHANES database from two data collection years (2015-2016 and 2017-2018). The exposure variable of this study was whether the participants had metal objects in the body or not. The outcome variables were blood concentrations of Cr and Co. Age, body mass index, sex, race/ethnicity, income to poverty ratio, tap water behavior, shellfish/fish/tuna/salmon eating habits, level of education, smoking behavior, marital status, blood hemoglobin, and data collection years were included as confounding variables. RESULTS A total of 4412 participants, aged 40 years or older, were included in this analysis, consisting of the without metal objects group (n = 3150) and the metal objects group (n = 1262). Metal objects was positively correlated to the accumulation of blood Cr (β = 0.072, 95% CI: 0.043-0.102, p < 0.001) and blood Co (β = 0.079, 95% CI: 0.049-0.109, p < 0.001). However, the positive correlation of metal objects with blood Cr was only presented in women (β = 0.112, 95% CI: 0.074-0.151, p < 0.001), but not in men. Meanwhile, the positive relationship between metal objects and blood Cr/Co was not observed in the Asian subgroup. CONCLUSIONS Blood Cr and Co concentrations were statistically higher in people with metal objects, but with race and sex differences. LEVEL OF EVIDENCE Level IV, cross-sectional study.
Collapse
Affiliation(s)
- Jinshen He
- grid.431010.7Department of Orthopaedic Surgery, the Third Xiangya Hospital of Central South University, Changsha, 410013 Hunan China
| | - Jinfei Li
- grid.431010.7Department of Orthopaedic Surgery, the Third Xiangya Hospital of Central South University, Changsha, 410013 Hunan China
| | - Song Wu
- grid.431010.7Department of Orthopaedic Surgery, the Third Xiangya Hospital of Central South University, Changsha, 410013 Hunan China
| | - Jiaoju Wang
- grid.216417.70000 0001 0379 7164Mathematics and Statistics School, Central South University, Changsha, 410000 Hunan China
| | - Qi Tang
- Department of Rheumatology and Immunology, the Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
| |
Collapse
|
3
|
Tognini M, Hothi H, Tucker S, Broomfield E, Shafafy M, Gikas P, Di Laura A, Henckel J, Hart A. Blood titanium levels in patients with large and sliding titanium implants. BMC Musculoskelet Disord 2022; 23:783. [PMID: 35974363 PMCID: PMC9380337 DOI: 10.1186/s12891-022-05717-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Titanium, which is known to be a highly biologically inert element, is one of the most commonly used metals in orthopaedic implants. While cobalt and chromium blood metal ion testing is routinely used in the clinical monitoring of patients with metal-on-metal hip implants, much less is known about the levels of titanium in patients with other implant types. The aim of this study was to better understand the normal ranges of blood titanium levels in patients implanted with large and sliding titanium constructs by comparison with reference levels from conventional titanium hips. Methods This study examined data collected from 136 patients. Over a period of 24 months, whole blood samples were collected from 41 patients implanted with large titanium implants: long (range 15 to 30 cm) spine rods with a sliding mechanism (“spine rods”, n = 18), long bone tumour implants (“tumour implants”, n = 13) and 3D-printed customised massive acetabular defect implants (“massive acetabular implants”, n = 10). This data was compared with standard, uncemented primary titanium hip implants (“standard hips”, 15 cm long) (n = 95). Clinical, imaging and blood titanium levels data were collected for all patients and compared statistically between the different groups. Results The median (range) of blood titanium levels of the standard hip, spine rods, femoral tumour implants and massive acetabular implants were 1.2 ppb (0.6–4.9), 9.7 ppb (4.0–25.4), 2.6 ppb (0.4–104.4) and 5.7 ppb (1.6–31.5) respectively. Spine rods and massive acetabular implants had significantly greater blood titanium levels compared to the standard hips group (p < 0.001). Conclusion This study showed that titanium orthopaedic implants that are large and/or have a sliding mechanism have higher blood titanium levels compared to well-functioning, conventionally sized titanium hips. Reassuringly, the increased levels did not appear to induce adverse metal reactions. This study provides useful baseline data for future studies aimed at assessing blood titanium levels as a biomarker for implant function.
Collapse
Affiliation(s)
- Martina Tognini
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.
| | - Harry Hothi
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Stewart Tucker
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Edel Broomfield
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Masood Shafafy
- Department of Trauma and Orthopaedics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Panos Gikas
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Anna Di Laura
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Johann Henckel
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Alister Hart
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| |
Collapse
|
4
|
Abdel Hamid OI, Attia ME, Hirshon JM, El-Shinawi M, El-Hussaini M, El-Setouhy M. Psychiatric Disorders and Genotoxicity Following Primary Metal on Polyethylene Total Hip Arthroplasty and Their Correlation to Cobalt/Chromium Levels. Drug Healthc Patient Saf 2022; 14:97-111. [PMID: 35880007 PMCID: PMC9308046 DOI: 10.2147/dhps.s360643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Hip arthroplasty (HA) using implantable metal components is among the commonest orthopedic interventions. However, it can be followed by several complications following corrosion and the release of metal ions. Several studies proved that damaged genomic DNA may contribute to the pathophysiology of mental disorders. Aim The current work aims to evaluate the psychiatric disorders in metal on polyethylene hip arthroplasty (MOP-HA) patients and its correlation to cobalt/chromium (Co/Cr) levels and genotoxicity. Methods The work was a longitudinal follow-up study including 34 adults with unilateral primary MOP-HA meeting the inclusion and exclusion criteria. Preoperatively, 6, 12-months-postoperatively, patients were examined for cognitive impairment using mini-mental-state-examination (MMSE), depression using major-depressive-inventory (MDI), and blood samples were collected for estimation of Co/Cr, detection of genotoxicity by single-cell-gel-electrophoresis (comet assay) and serum 8-hydroxy-2'-deoxyguanosine (8-OHdG). Results Cognitive impairment was reported in 18.5% and 14.8% at 6-months, and 12-months postoperative, respectively. Depressive disorder was recorded in 22.2% at 6-months and 14.8% at 12-months postoperative. The marginal homogeneity tests proved a non-significant difference. There was a non-significant difference in preoperative, 6-months, 12-months postoperative MMSE, and MDI scores. There were significantly increased Co/Cr levels at 6-months postoperative. The levels decreased at 12-months postoperative, however, still significantly higher than preoperative values. There was a significant increase in serum 8-OHdG and the levels were positively correlated to cobalt levels at both 6 and 12-months-postoperative. There was a non-significant difference among preoperative, 6-months, and 12-months postoperative comet assay measurements. Conclusion From previous findings, we can conclude that will-functioning MOP hip arthroplasty can induce increased ion levels and positively correlated increase in biochemical markers of genotoxicity (8-OHdG).
Collapse
Affiliation(s)
- Omaima I Abdel Hamid
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed E Attia
- Orthopedics Departments, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Jon M Hirshon
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, MD, USA
- Department of Epidemiology and Public Health, University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Mohamed El-Shinawi
- Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Galala University, Galala City, Suez, Egypt
| | - Moustafa El-Hussaini
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Maged El-Setouhy
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Department of Family and Community Medicine, Faculty of Medince, Jazan University, Jazan, Kingdom of Saudi Arabia
| |
Collapse
|
5
|
Lüders KA, Braunschweig L, Zioła-Frankowska A, Stojek A, Jakkielska D, Wichmann A, Dihazi GH, Streit F, Güsewell SE, Trüe TC, Lüders S, Schlie J, Tsaknakis K, Lorenz HM, Frankowski M, Hell AK. Titanium wear from magnetically controlled growing rods (MCGRs) for the treatment of spinal deformities in children. Sci Rep 2022; 12:10811. [PMID: 35752736 PMCID: PMC9233686 DOI: 10.1038/s41598-022-15057-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/17/2022] [Indexed: 11/29/2022] Open
Abstract
Magnetically controlled growing rods (MCGRs) are an effective treatment method for early-onset scoliosis (EOS). In recent years, increasing titanium wear was observed in tissue adjacent to implants and in blood samples of these patients. This study aims to investigate the potential correlation between amount of metal loss and titanium levels in blood during MCGR treatment as well as influencing factors for metal wear. In total, 44 MCGRs (n = 23 patients) were retrieved after an average of 2.6 years of implantation and analyzed using a tactile measurement instrument and subsequent metal loss calculation. Titanium plasma levels (n = 23) were obtained using inductively coupled plasma-mass spectrometry (ICP-MS). The correlation of both parameters as well as influencing factors were analyzed. Titanium abrasion on MCGRs was observed in the majority of implants. There was no correlation of metal implant wear or titanium plasma values to the duration of MCGR implantation time, number of external lengthening procedures, patient’s ambulatory status, gender, weight or height. Material loss on the MCGRs showed a positive correlation to titanium blood plasma values. The present study is one of the first studies to analyze retrieved MCGRs using high-precision metrological techniques and compare these results with ICP-MS analyses determining blood titanium values.
Collapse
Affiliation(s)
- K A Lüders
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - L Braunschweig
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | | | - A Stojek
- Faculty of Chemistry, Adam Mickiewicz University, Poznan, Poland
| | - D Jakkielska
- Faculty of Chemistry, Adam Mickiewicz University, Poznan, Poland
| | - A Wichmann
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - G H Dihazi
- Clinical Chemistry, University Medical Center Göttingen, Göttingen, Germany
| | - F Streit
- Clinical Chemistry, University Medical Center Göttingen, Göttingen, Germany
| | - S E Güsewell
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - T C Trüe
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | | | | | - K Tsaknakis
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - H M Lorenz
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - M Frankowski
- Faculty of Chemistry, Adam Mickiewicz University, Poznan, Poland
| | - A K Hell
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany.
| |
Collapse
|
6
|
Have you caught that outlier yet? Evaluate the utility of repeat testing in nutritional and toxic element assessment. Clin Chim Acta 2022; 528:84-89. [PMID: 35104463 DOI: 10.1016/j.cca.2022.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 11/21/2022]
Abstract
Repeat testing is routinely required by regulatory bodies as a measure to rule out contamination in trace elements and heavy metal analysis, especially when the initial analysis result is outside the reference interval. However, its clinical utilities in detecting analytical measurement outliers have not been systematically evaluated in different clinical testing scenarios. In this study, we present an extensive evaluation of repeat testing and its comparison with the initial analysis in four serum and plasma trace element assays performed by inductively coupled plasma mass spectrometry. We demonstrate that the patient population distributions for these elements differ significantly from the reference interval established by healthy individuals. Accordingly, a significant proportion of the patient specimens required repeat testing when using reference intervals as the threshold to perform repeat analysis. Crucially, comparison of the first analysis and repeat analysis revealed the limited utility of performing repeat measurements. The relative differences between the first and second measurements are consistent with the observed analytical imprecision of the assay and the likelihood of detecting actual analytical outliers is very low.
Collapse
|
7
|
Jeuken RM, Fransz DP, Geers MGD, van Maris MPFHL, Ten Broeke RHM. Failure Mode Analysis of an Exeter Stem Fracture Initiated at the Introducer Hole: Time for a Design Change? Arthroplast Today 2021; 11:196-204. [PMID: 34746345 PMCID: PMC8551419 DOI: 10.1016/j.artd.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 11/03/2022] Open
Abstract
The fracturing of a hip prosthesis stem at its neck, in the absence of a trauma, is an extremely rare but serious adverse event. The patient in our case was young, active, and tall, thereby putting high mechanical loads on the prosthesis. Radiographs of the initial procedure and blood and synovium analysis showed no abnormalities. Analysis of the stem revealed niobium-rich precipitates, that is, alloy artifacts, at the introducer stud hole. The mechanically vulnerable location of the introducer stud hole, combined with alloy artifacts at that location and high mechanical stress, ultimately led to failure of the prosthesis. As younger and heavier patients will demand hip arthroplasty in the future, simple stem design adaptations should be considered to prevent stem fractures at the introducer stud hole.
Collapse
Affiliation(s)
- Ralph M Jeuken
- Department of Orthopaedics, Maastricht University Medical Center, Maastricht, Limburg, the Netherlands.,Department of Orthopaedics, Zuyderland Medical Center, Heerlen, Limburg, the Netherlands
| | - Duncan P Fransz
- Department of Orthopaedics, Maastricht University Medical Center, Maastricht, Limburg, the Netherlands
| | - Marc G D Geers
- Department of Mechanical Engineering, Eindhoven University of Technology, Eindhoven, Noord-Brabant, the Netherlands
| | - Marc P F H L van Maris
- Department of Mechanical Engineering, Eindhoven University of Technology, Eindhoven, Noord-Brabant, the Netherlands
| | - René H M Ten Broeke
- Department of Orthopaedics, Maastricht University Medical Center, Maastricht, Limburg, the Netherlands
| |
Collapse
|
8
|
Badhe RV, Bijukumar D, Mesquita P, Cheng KY, Ramachandran RA, Lin Y, Mathew MT. Dynamic microfluidic bioreactor-Hip simulator (DMBH) system for implant toxicity monitoring. Biotechnol Bioeng 2021; 118:4829-4839. [PMID: 34596239 DOI: 10.1002/bit.27946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/18/2021] [Accepted: 09/27/2021] [Indexed: 11/07/2022]
Abstract
The generation of degradation products (DPs) like ions and organo-metallic particles from corroding metallic implants is an important healthcare concern. These DPs generate local and systemic toxicity. The impact on local toxicity is well documented, however, little is known about systemic toxicity. This is mainly due to the limited scope of the current microtiter plate-based (static) toxicity assay techniques. These methods do not mimic the systemic (dynamic) conditions. In this study, it is hypothesized that DPs incubated with cells in static conditions might provide improper systemic toxicity results, as there is no movement mimicking the blood circulation around cells. This study reports the development of a three-chambered prototype microfluidic system connected to the operational hip implant simulator to test the cellular response induced by the DPs. This setup is called a dynamic microfluidic bioreactor-hip simulator system. We hypothesize that a dynamic microfluidic system will provide a realistic toxicology response induced by DPs than a static cell culture plate. To prove the hypothesis, Neuro2a (N2a) cells were used as representative cells to study systemic neurotoxicity by the implant DPs. The microfluidic bioreactor system was validated by comparing the cell toxicity against the traditional static system and using COMSOL modeling for media flow with DPs. The hip implant simulator used in this study was a state-of-the-art sliding hip simulator developed in our lab. The results suggested that static toxicity was significantly more compared to dynamic microfluidic-based toxicity. The newly developed DMBH system tested for in situ systemic toxicity on N2a cells and demonstrated very minimum toxicity level (5.23%) compared to static systems (31.16%). Thus, the new DMBH system is an efficient tool for in situ implant metal systemic toxicity testing.
Collapse
Affiliation(s)
- Ravindra V Badhe
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, Illinois, USA
| | - Divya Bijukumar
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, Illinois, USA
| | - Pedro Mesquita
- Department of Mechanical, Industrial and Systems Engineering, University of Rhode Island, Kingston, Rhode Island, USA
| | - Kai Yuan Cheng
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, Illinois, USA
| | - Remya Ampadi Ramachandran
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, Illinois, USA
| | - Yang Lin
- Department of Mechanical, Industrial and Systems Engineering, University of Rhode Island, Kingston, Rhode Island, USA
| | - Mathew T Mathew
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, Illinois, USA
| |
Collapse
|
9
|
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.
Collapse
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.
| |
Collapse
|
10
|
Yang HS, LaFrance DR, Hao Y. Elemental Testing Using Inductively Coupled Plasma Mass Spectrometry in Clinical Laboratories. Am J Clin Pathol 2021; 156:167-175. [PMID: 33978166 DOI: 10.1093/ajcp/aqab013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES This review aims to describe the principles underlying different types of inductively coupled plasma mass spectrometry (ICP-MS), and major technical advancements that reduce spectral interferences, as well as their suitability and wide applications in clinical laboratories. METHODS A literature survey was performed to review the technical aspects of ICP-MS, ICP-MS/MS, high-resolution ICP-MS, and their applications in disease diagnosis and monitoring. RESULTS Compared to the atomic absorption spectrometry and ICP-optical emission spectrometry, ICP-MS has advantages including improved precision, sensitivity and accuracy, wide linear dynamic range, multielement measurement capability, and ability to perform isotopic analysis. Technical advancements, such as collision/reaction cells, triple quadrupole ICP-MS, and sector-field ICP-MS, have been introduced to improve resolving power and reduce interferences. Cases are discussed that highlight the clinical applications of ICP-MS including determination of toxic elements, quantification of nutritional elements, monitoring elemental deficiency in metabolic disease, and multielement analysis. CONCLUSIONS This review provides insight on the strategies of elemental analysis in clinical laboratories and demonstrates current and emerging clinical applications of ICP-MS.
Collapse
Affiliation(s)
- He S Yang
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
- NewYork Presbyterian Hospital, Weill Cornell Medical Campus, New York, NY, USA
| | | | - Ying Hao
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
11
|
Jenkinson MRJ, Meek RMD, Tate R, MacMillan S, Grant MH, Currie S. Cobalt-induced cardiomyopathy - do circulating cobalt levels matter? Bone Joint Res 2021; 10:340-347. [PMID: 34053230 PMCID: PMC8242681 DOI: 10.1302/2046-3758.106.bjr-2020-0414.r2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Elevated levels of circulating cobalt ions have been linked with a wide range of systemic complications including neurological, endocrine, and cardiovascular symptoms. Case reports of patients with elevated blood cobalt ions have described significant cardiovascular complications including cardiomyopathy. However, correlation between the actual level of circulating cobalt and extent of cardiovascular injury has not previously been performed. This review examines evidence from the literature for a link between elevated blood cobalt levels secondary to metal-on-metal (MoM) hip arthroplasties and cardiomyopathy. Correlation between low, moderate, and high blood cobalt with cardiovascular complications has been considered. Elevated blood cobalt at levels over 250 µg/l have been shown to be a risk factor for developing systemic complications and published case reports document cardiomyopathy, cardiac transplantation, and death in patients with severely elevated blood cobalt ions. However, it is not clear that there is a hard cut-off value and cardiac dysfunction may occur at lower levels. Clinical and laboratory research has found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. Further work needs to be done to clarify the link between severely elevated blood cobalt ions and cardiomyopathy. Cite this article: Bone Joint Res 2021;10(6):340–347.
Collapse
Affiliation(s)
| | | | - Rothwell Tate
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | | | - M Helen Grant
- Biomedical Engineering, University of Strathclyde, Glasgow, UK
| | - Susan Currie
- Biomedical Engineering, University of Strathclyde, Glasgow, UK
| |
Collapse
|
12
|
Chen W, Zhu WQ, Qiu J. Impact of exogenous metal ions on peri-implant bone metabolism: a review. RSC Adv 2021; 11:13152-13163. [PMID: 35423842 PMCID: PMC8697588 DOI: 10.1039/d0ra09395e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/25/2021] [Indexed: 11/21/2022] Open
Abstract
The development of effective methods to promote the osseointegration of dental implants by surface modification is an area of intense research in dental materials science. Exogenous metal ions present in the implant and surface modifications are closely related to the bone metabolism around the implant. In the complex oral microenvironment, the release of metal ions caused by continuous corrosion of dental implants has an unfavorable impact on the surrounding tissue, and then affects osseointegration, leading to bad results such as loosening and falling off in the late stage of the implant. Besides, these ions can even be distributed in distant tissues and organs. Currently, surface modification techniques are being developed that involve different processing technologies including the introduction of exogenous metal ions with different properties onto the surface of implants to improve performance. However, most metal elements have some level of biological toxicity and can only be used within a safe concentration range to exert the optimum biological effects on recipients. In this paper, we review the adverse effects of metal ions on osseointegration and highlight the emerging applications for metal elements in improving the performance of dental implants.
Collapse
Affiliation(s)
- Wei Chen
- Department of Oral Implantology, Affiliated Hospital of Stomatology, Nanjing Medical University Nanjing 210029 PR China +86 25 69593085
- Jiangsu Key Laboratory of Oral Disease, Nanjing Medical University Nanjing 210029 PR China
| | - Wen-Qing Zhu
- Department of Oral Implantology, Affiliated Hospital of Stomatology, Nanjing Medical University Nanjing 210029 PR China +86 25 69593085
- Jiangsu Key Laboratory of Oral Disease, Nanjing Medical University Nanjing 210029 PR China
| | - Jing Qiu
- Department of Oral Implantology, Affiliated Hospital of Stomatology, Nanjing Medical University Nanjing 210029 PR China +86 25 69593085
- Jiangsu Key Laboratory of Oral Disease, Nanjing Medical University Nanjing 210029 PR China
| |
Collapse
|
13
|
Qin HM, Herrera D, Liu DF, Chen CQ, Nersesyan A, Mišík M, Knasmueller S. Genotoxic properties of materials used for endoprostheses: Experimental and human data. Food Chem Toxicol 2020; 145:111707. [PMID: 32889016 DOI: 10.1016/j.fct.2020.111707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/13/2020] [Accepted: 08/22/2020] [Indexed: 12/28/2022]
Abstract
Approximately 2 million endoprostheses are implanted annually and metal ions as well as particles are released into the body from the materials which are used. This review describes the results of studies concerning genotoxic damage caused by artificial joints. DNA damage leads to various adverse long-term health effects in humans including cancer. Experiments with mammalian cells showed that metal ions and particles from orthopedic materials cause DNA damage. Induction of chromosomal aberrations (CA) was found in several in vitro experiments and in studies with rodents with metals from orthopedic materials. Human studies focused mainly on induction of CA (7 studies). Only few investigations (4) concerned sister chromatid exchanges, oxidative DNA damage (2) and micronucleus formation (1). CA are a reliable biomarker for increased cancer risks in humans) and were increased in all studies in patients with artificial joints. No firm conclusion can be drawn at present if the effects in humans are due to oxidative stress and if dissolved metal ions or release particles play a role. Our findings indicate that patients with artificial joints may have increased cancer risks due to damage of the genetic material. Future studies should be performed to identify safe materials and to study the molecular mechanisms in detail.
Collapse
Affiliation(s)
- Hong-Min Qin
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Denise Herrera
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Dian-Feng Liu
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Chao-Qian Chen
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Armen Nersesyan
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Miroslav Mišík
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Siegfried Knasmueller
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria.
| |
Collapse
|
14
|
Mehta N, Hall DJ, Pourzal R, Garrigues GE. The Biomaterials of Total Shoulder Arthroplasty: Their Features, Function, and Effect on Outcomes. JBJS Rev 2020; 8:e1900212. [PMID: 32890047 DOI: 10.2106/jbjs.rvw.19.00212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The materials that are used in total shoulder arthroplasty (TSA) implants have been carefully chosen in an attempt to minimize hardware-related complications. The 2 main metal alloys used in TSA implants are Ti-6Al-4V (titanium-aluminum-vanadium) and CoCrMo (cobalt-chromium-molybdenum). Ti alloys are softer than CoCr alloys, making them less wear-resistant and more susceptible to damage, but they have improved osseointegration and osteoconduction properties. Although controversial, metal allergy may be a concern in patients undergoing TSA and may lead to local tissue reaction and aseptic loosening. Numerous modifications to polyethylene, including cross-linking, minimizing oxidation, and vitamin E impregnation, have been developed to minimize wear and reduce complications. Alternative bearing surfaces such as ceramic and pyrolytic carbon, which have strong track records in other fields, represent promising possibilities to enhance the strength and the durability of TSA prostheses.
Collapse
Affiliation(s)
- Nabil Mehta
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Deborah J Hall
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Robin Pourzal
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Grant E Garrigues
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
15
|
Wani SA, Khan LA, Basir SF. Cobalt-Induced Hypercontraction is Mediated by Generationof Reactive Oxygen Species and Influx of Calcium in Isolated RatAorta. Biol Trace Elem Res 2020; 196:110-118. [PMID: 31520195 DOI: 10.1007/s12011-019-01890-5] [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: 05/11/2019] [Accepted: 08/29/2019] [Indexed: 10/26/2022]
Abstract
To investigate the mechanism of cobalt-mediated phenylephrine (PE)-induced contraction in endothelium-intact isolated Wistar rat aortic rings. Effect of dose-dependent concentrations of cobalt on PE-induced contraction was investigated in isolated Wistar rat aortic rings using an organ bath system. Aortic rings were pre-incubated with verapamil (1 μM and 20 μM), gadolinium, apocynin, indomethacin or N-G-nitro-L-arginine methyl ester (L-NAME) separately before incubation with cobalt. Endothelium-intact aortic rings were incubated with 800 nM, 1 μM, 10 μM, 50 μM cobalt; we observed 20%, 22%, 32% and 27% increased contractions respectively, while no effect was seen in tension recording on cobalt exposure. Incubation of endothelium-intact aortic rings with 100 μM apocynin and 100 μM L-NAME suggested the role of NADPH oxidase in generation of reactive oxygen species (ROS) and decrease in bioavailability of nitric oxide (NO) from eNOS on exposure to cobalt. Aortic rings pre-incubated with 1 μM and 20 μM verapamil suggested role of both L-type and T-type calcium channels in influx of extracellular calcium in smooth muscle cells. We observed no role of store-operated calcium channels (SOCC) in calcium influx due to cobalt exposure and cyclooxygenase in generation of prostanoids in isolated aortic rings. Cobalt caused rise of PE-induced contractions as a result of the endothelial generation of ROS, by decreasing bioavailability of NO. Generation of ROS may be responsible for causing the influx of extracellular calcium through L-type and T-type Ca2+ channels in smooth muscle cells.
Collapse
Affiliation(s)
| | - Luqman Ahmad Khan
- Department of Biosciences, Jamia Millia Islamia, New Delhi, 110025, India
| | - Seemi Farhat Basir
- Department of Biosciences, Jamia Millia Islamia, New Delhi, 110025, India.
| |
Collapse
|
16
|
Goderecci R, Fidanza A, Necozione S, Francione V, Indelli PF, Calvisi V. Ultrasound-based decision making following metal-on-metal hip arthroplasty. J Clin Orthop Trauma 2020; 11:79-84. [PMID: 32001990 PMCID: PMC6985022 DOI: 10.1016/j.jcot.2019.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 04/13/2019] [Accepted: 04/15/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Metal-on-Metal (MoM) total hip arthroplasty (THA) represents a very controversial procedure because of the possibility of postoperative adverse local tissue reaction (ALTR). This study investigates the reliability of the ultrasound scan as a diagnostic tool to quantify a clinically useful threshold in the level of periprosthetic fluid collection to suggest implant revision. METHODS This study includes 116 patients (123 implants) who received an Articular Surface Replacement XL (ASRTMXL, De Puy Synthes, USA) MoM THA. The study group included 56 males and 60 females with a mean age of 66.6 years (range, 15-86 years). All patients were clinically and radiologically annually evaluated (according to the Harris Hip Score) up to a mean follow-up of 7.5 years (min. 1.4 - max. 10.3 years) from the primary surgery: all patients underwent standard ultrasound evaluation of the affected hip and Cobalt/Chromium blood detection testing according to a custom-made diagnostic algorithm for MoM THA revision. RESULTS At final follow-up, 51 (43.1%) of 117 implants underwent revision after a mean of 6 years (1.79-9.26) from the primary ASR implant. The authors found a statistically significant correlation between Cr (p = 0.015) and Co (p = 0.009) blood values and different ultrasound grades. Statistical analysis showed a significant association between periprosthetic fluid collection and revision surgery (p < 0.0001) and the final revision risk was estimated to be 7 times greater in patients with ultrasound grade ≥ 2 (peri-prosthetic collection ≥ 20 mm). CONCLUSIONS This study confirms the reliability of ultrasound evaluation in detecting clinically significant peri-prosthetic joint effusions: a new diagnostic algorithm for MoM THA revision is here presented. Longer follow up studies are mandatory to better understand the potential advantages of this diagnostic protocol.
Collapse
Affiliation(s)
- Remo Goderecci
- Department of Life, Health & Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, Blocco 11, 67100, L'Aquila, Italy
- Corresponding author. Department of Life, Health & Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, Blocco 11, 67100, L'Aquila, Italy.
| | - Andrea Fidanza
- Department of Life, Health & Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, Blocco 11, 67100, L'Aquila, Italy
| | - Stefano Necozione
- Department of Life, Health & Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, Blocco 11, 67100, L'Aquila, Italy
| | - Vincenzo Francione
- Unità di Ortopedia, Casa di Cura Privata Villa Anna, Via Toscana 159, 63039, San Benedetto del Tronto, AP, Italy
| | - Pier Francesco Indelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine, 450 Broadway, Redwood City, CA, 94063, USA
| | - Vittorio Calvisi
- Department of Life, Health & Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, Blocco 11, 67100, L'Aquila, Italy
| |
Collapse
|
17
|
Swiatkowska I, Martin NG, Henckel J, Apthorp H, Hamshere J, Hart AJ. Blood and plasma titanium levels associated with well-functioning hip implants. J Trace Elem Med Biol 2020; 57:9-17. [PMID: 31546210 DOI: 10.1016/j.jtemb.2019.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/28/2019] [Accepted: 09/13/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hip implants are usually manufactured from cobalt-chromium and titanium alloys. As the implants wear and corrode, metal debris is released into the surrounding tissue and blood, providing a potential biomarker for their function. Whilst there are laboratory reference levels for blood cobalt and chromium in patients with well and poorly functioning hip implants, there are no such guidelines for titanium. This is despite the increasing use of titanium implants worldwide. PATIENTS AND METHODS We recruited a consecutive series of 95 patients (mean age 71 years, mean time after surgery 8.5 years) with one hip implant type, inserted by the same surgeon. We assessed clinical and radiological outcome, and measured blood and plasma titanium using high resolution inductively-coupled plasma mass spectrometry. RESULTS The upper normal reference limit for blood and plasma titanium was 2.20 and 2.56 μg L-1, respectively, and did not differ significantly between males and females. CONCLUSION We are the first to propose a laboratory reference level for blood and plasma titanium in patients with well-functioning titanium hip implants. This is an essential starting point for further studies to explore the clinical usefulness of blood titanium as a biomarker of orthopaedic implant performance, and comes at a time of considerable controversy regarding the use of certain titanium alloys in hip arthroplasty.
Collapse
Affiliation(s)
- Ilona Swiatkowska
- Institute of Orthopaedics and Musculoskeletal Science, University College London, HA7 4LP Stanmore, UK.
| | - Nicholas G Martin
- Trace Element Laboratory, North West London Pathology, Charing Cross Hospital, W6 8RF London, UK
| | - Johann Henckel
- Royal National Orthopaedic Hospital, Stanmore, HA7 4LP Stanmore, UK
| | | | | | - Alister J Hart
- Institute of Orthopaedics and Musculoskeletal Science, University College London, HA7 4LP Stanmore, UK; Royal National Orthopaedic Hospital, Stanmore, HA7 4LP Stanmore, UK
| |
Collapse
|
18
|
Morrell AP, Floyd H, W Mosselmans JF, Grover LM, Castillo-Michel H, Davis ET, Parker JE, Martin RA, Addison O. Improving our understanding of metal implant failures: Multiscale chemical imaging of exogenous metals in ex-vivo biological tissues. Acta Biomater 2019; 98:284-293. [PMID: 31173961 DOI: 10.1016/j.actbio.2019.05.071] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 12/20/2022]
Abstract
Biological exposures to micro- and nano-scale exogenous metal particles generated as a consequence of in-service degradation of orthopaedic prosthetics can result in severe adverse tissues reactions. However, individual reactions are highly variable and are not easily predicted, due to in part a lack of understanding of the speciation of the metal-stimuli which dictates cellular interactions and toxicity. Investigating the chemistry of implant derived metallic particles in biological tissue samples is complicated by small feature sizes, low concentrations and often a heterogeneous speciation and distribution. These challenges were addressed by developing a multi-scale two-dimensional X-ray absorption spectroscopic (XAS) mapping approach to discriminate sub-micron changes in particulate chemistry within ex-vivo tissues associated with failed CoCrMo total hip replacements (THRs). As a result, in the context of THRs, we demonstrate much greater variation in Cr chemistry within tissues compared with previous reports. Cr compounds including phosphate, hydroxide, oxide, metal and organic complexes were observed and correlated with Co and Mo distributions. This variability may help explain the lack of agreement between biological responses observed in experimental exposure models and clinical outcomes. The multi-scale 2D XAS mapping approach presents an essential tool in discriminating the chemistry in dilute biological systems where speciation heterogeneity is expected. SIGNIFICANCE: Metal implants are routinely used in healthcare but may fail following degradation in the body. Although specific implants can be identified as 'high-risk', our analysis of failures is limited by a lack of understanding of the chemistry of implant metals within the peri-prosthetic milieu. A new approach to identify the speciation and variability in speciation at sub-micron resolution, of dilute exogenous metals within biological tissues is reported; applied to understanding the failure of metallic (CoCrMo) total-hip-replacements widely used in orthopedic surgery. Much greater variation in Cr chemistry was observed compared with previous reports and included phosphate, hydroxide, oxide, metal and organic complexes. This variability may explain lack of agreement between biological responses observed in experimental exposure models and clinical outcomes.
Collapse
Affiliation(s)
| | - Hayley Floyd
- University of Birmingham, Birmingham B15 2TT, UK
| | | | | | | | | | | | | | - Owen Addison
- University of Birmingham, Birmingham B15 2TT, UK; University of Alberta, Edmonton, AB T6G, Canada.
| |
Collapse
|
19
|
Swiatkowska I, Martin N, Hart AJ. Blood titanium level as a biomarker of orthopaedic implant wear. J Trace Elem Med Biol 2019; 53:120-128. [PMID: 30910194 DOI: 10.1016/j.jtemb.2019.02.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/18/2019] [Accepted: 02/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Joint replacement implants are usually manufactured from cobalt-chromium or titanium alloys. After the device is implanted, wear and corrosion generate metal particles and ions, which are released into local tissue and blood. The metal debris can cause a range of adverse local and systemic effects in patients. RESEARCH PROBLEM In the case of cobalt and chromium, a blood level exceeding 7 μg L-1 indicates potential for local toxicity, and a failing implant. It has been repeatedly suggested in the literature that measurement of titanium could also be used to assess implant function. Despite an increasing interest in this biomarker, and growing use of titanium in orthopaedics, it is unclear what blood concentrations should raise concerns. This is partly due to the technical challenges involved in the measurement of titanium in biological samples. AIM This Review summarises blood/serum titanium levels associated with well-functioning and malfunctioning prostheses, so that the prospects of using titanium measurements to gain insights into implant performance can be evaluated. CONCLUSION Due to inter-laboratory analytical differences, reliable conclusions regarding "normal" and "abnormal" titanium levels in patients with orthopaedic implants are difficult to draw. Diagnosis of symptomatic patients should be based on radiographic evidence combined with blood/serum metal levels.
Collapse
Affiliation(s)
- Ilona Swiatkowska
- Institute of Orthopaedics and Musculoskeletal Science, University College London, HA7 4LP, Stanmore, UK.
| | - Nicholas Martin
- Trace Element Laboratory, Clinical Biochemistry, Charing Cross Hospital, W6 8RF, London, UK
| | - Alister J Hart
- Institute of Orthopaedics and Musculoskeletal Science, University College London, HA7 4LP, Stanmore, UK; Royal National Orthopaedic Hospital, Stanmore, HA7 4LP, UK
| |
Collapse
|
20
|
Kovochich M, Finley BL, Novick R, Monnot AD, Donovan E, Unice KM, Fung ES, Fung D, Paustenbach DJ. Understanding outcomes and toxicological aspects of second generation metal-on-metal hip implants: a state-of-the-art review. Crit Rev Toxicol 2019; 48:853-901. [DOI: 10.1080/10408444.2018.1563048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
21
|
Delgado-Ruiz R, Romanos G. Potential Causes of Titanium Particle and Ion Release in Implant Dentistry: A Systematic Review. Int J Mol Sci 2018; 19:E3585. [PMID: 30428596 PMCID: PMC6274707 DOI: 10.3390/ijms19113585] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/09/2018] [Accepted: 11/11/2018] [Indexed: 01/03/2023] Open
Abstract
Implant surface characteristics, as well as physical and mechanical properties, are responsible for the positive interaction between the dental implant, the bone and the surrounding soft tissues. Unfortunately, the dental implant surface does not remain unaltered and changes over time during the life of the implant. If changes occur at the implant surface, mucositis and peri-implantitis processes could be initiated; implant osseointegration might be disrupted and bone resorption phenomena (osteolysis) may lead to implant loss. This systematic review compiled the information related to the potential sources of titanium particle and ions in implant dentistry. Research questions were structured in the Population, Intervention, Comparison, Outcome (PICO) framework. PICO questionnaires were developed and an exhaustive search was performed for all the relevant studies published between 1980 and 2018 involving titanium particles and ions related to implant dentistry procedures. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for the selection and inclusion of the manuscripts in this review. Titanium particle and ions are released during the implant bed preparation, during the implant insertion and during the implant decontamination. In addition, the implant surfaces and restorations are exposed to the saliva, bacteria and chemicals that can potentially dissolve the titanium oxide layer and, therefore, corrosion cycles can be initiated. Mechanical factors, the micro-gap and fluorides can also influence the proportion of metal particles and ions released from implants and restorations.
Collapse
Affiliation(s)
- Rafael Delgado-Ruiz
- Department of Prosthodontics and Digital Technology, School of Dental Medicine, Stony Brook University, New York, NY 11794, USA.
| | - Georgios Romanos
- Department of Periodontics, School of Dental Medicine, Stony Brook University, New York, NY 11794, USA.
- Department of Oral Surgery and Implant Dentistry, Dental School, Johann Wolfgang Goethe University, 60323 Frankfurt, Germany.
| |
Collapse
|
22
|
Molecular pathology of adverse local tissue reaction caused by metal-on-metal implants defined by RNA-seq. Genomics 2018; 111:1404-1411. [PMID: 30248488 DOI: 10.1016/j.ygeno.2018.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/13/2018] [Accepted: 09/17/2018] [Indexed: 12/18/2022]
Abstract
Total hip arthroplasty (THA) alleviates hip pain and improves joint function. Current implant design permits long-term survivorship of THAs, but certain metal-on-metal (MoM) articulations can portend catastrophic failure due to adverse local tissue reactions (ALTR). Here, we identified biological and molecular differences between periacetabular synovial tissues of patients with MoM THA failure undergoing revision THA compared to patients undergoing primary THA for routine osteoarthritis (OA). Analysis of tissue biopsies by RNA-sequencing (RNA-seq) revealed that MoM patient samples exhibit significantly increased expression of immune response genes but decreased expression of genes related to extracellular matrix (ECM) remodeling. Thus, interplay between local tissue inflammation and ECM degradation may account for the pathology and compromised clinical outcomes in select patients with MoM implants. We conclude that adverse responses of host tissues to implant materials result in transcriptomic modifications in patients with MoM implants that permit consideration of strategies that could mitigate ECM damage.
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Ho JH, Leikin JB, Dargan PI, Archer JRH, Wood DM, Brent J. Metal-on-Metal Hip Joint Prostheses: a Retrospective Case Series Investigating the Association of Systemic Toxicity with Serum Cobalt and Chromium Concentrations. J Med Toxicol 2017; 13:321-328. [PMID: 28900863 PMCID: PMC5711759 DOI: 10.1007/s13181-017-0629-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/09/2017] [Accepted: 08/17/2017] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION There have been concerns about prosthesis failure and the potential for systemic toxicity due to release of cobalt and chromium from metal-on-metal hip joint prostheses (MoM-HP). There is conflicting evidence on whether there is a correlation between higher cobalt and chromium concentrations and systemic toxicity. METHODS We undertook a retrospective review of consecutive patients with MoM-HP referred for outpatient review in toxicology clinics in London, UK, and in the USA recorded in the Toxicology Investigators Consortium (ToxIC) Registry from June 2011 to June 2015. RESULTS Thirty-one cases were identified; the median (IQR) serum cobalt concentration was 10.0 (3.8-32.8) mcg/L, and the median (IQR) serum chromium concentration was 6.9 (3.7-18.7) mcg/L. Twenty-three (74.2%) had symptoms, most commonly lethargy, hearing loss, and tinnitus. The odds ratios of symptomatic/asymptomatic patients for metal ion concentrations above/below 7 mcg/L were 1.87 (95% CI 0.37-9.57, p = 0.45) and 0.60 (95% CI 0.10-3.50, p = 0.57) for cobalt and chromium, respectively. Two (6.5%) patients with systemic cobalt toxicity had median (IQR) serum cobalt concentrations significantly higher than those without systemic features (630.4 [397.6-863.2] mcg/L versus 9.8 [2.9-16.4] mcg/L; p = 0.017). However, overall, there were no differences between cobalt (p = 0.38) or chromium (p = 0.92) concentrations between symptomatic and asymptomatic patients and no clinical features or investigation results correlated with cobalt or chromium concentration. CONCLUSION Two (6.5%) of 31 individuals referred for assessment of MoM-HP were diagnosed with systemic cobalt toxicity. However, despite a high prevalence of reported symptoms, neither symptoms nor investigation results correlated with serum cobalt or chromium concentrations.
Collapse
Affiliation(s)
- James H Ho
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jerrold B Leikin
- Medical Toxicology, Glenbrook Hospital, NorthShore University Health System-OMEGA, Glenview, IL, USA
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK.
- Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jeffrey Brent
- School of Medicine, University of Colorado, Aurora, CO, USA
| |
Collapse
|
25
|
Reiner T, Do TD, Klotz MC, Hertzsch F, Seelmann K, Gaida MM, Weber MA, Gotterbarm T. MRI Findings in Patients After Small-Head Metal-on-Metal Total Hip Arthroplasty with a Minimum Follow-up of 10 Years. J Bone Joint Surg Am 2017; 99:1540-1546. [PMID: 28926383 DOI: 10.2106/jbjs.16.01021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Concern has been raised about the late onset of adverse reactions to metal debris (ARMD) in patients with a small-head metal-on-metal total hip replacement. The aims of this study were to assess the frequency and characteristic appearance of ARMD in patients with a small-head (28-mm) metal-on-metal total hip replacement and elevated blood ion levels (>1 μg/L) after a minimum follow-up of 10 years and to analyze the possible risk factors associated with the prevalence of these lesions. METHODS In the present study, we used metal artifact reduction sequence magnetic resonance imaging (MARS MRI) to investigate the cases of 53 patients (66 hips) with a small-head (28-mm) metal-on-metal total hip replacement and elevated blood ion levels at a mean follow-up interval of 15.5 years (range, 10.6 to 19.3 years). Whole blood metal ion levels (cobalt and chromium), clinical outcome scores (Harris hip score), and radiographs were obtained for each patient. Tissue samples from patients who had revision surgery were histologically examined. RESULTS MARS MRI revealed ARMD in 27 hips (41%). Most hips with ARMD (67%) were asymptomatic. ARMD were generally small, with a median lesion size of 2.3 cm (range, 0.3 to 71.4 cm) and predominantly cystic in nature. Multivariate regression analysis revealed positive correlation between cobalt ion levels and the presence of ARMD. In this case series, the risk for the development of ARMD was 2.87 times higher for every 1 μg/L increase of blood cobalt ion concentration (95% confidence interval, 1.01 to 8.17; p = 0.048). CONCLUSIONS In this case series, ARMD were seen in 41% of the hips following small-head metal-on-metal total hip arthroplasty at long-term follow-up, and most patients with ARMD were asymptomatic. Blood cobalt ion levels could be identified as a risk factor for ARMD. However, ARMD also occurred in patients with low metal ion levels. Further studies are necessary to investigate the role of ARMD in asymptomatic patients with this bearing type. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Tobias Reiner
- 1Center for Orthopedics, Trauma Surgery and Spinal Cord Injury (T.R., M.C.K., F.H., K.S., and T.G.), and Department of Diagnostic and Interventional Radiology (T.D.D. and M.-A.W.), Heidelberg University Hospital, Heidelberg, Germany 2Institute for Pathology, University of Heidelberg, Heidelberg, Germany
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Koch KM, Koff MF, Bauer TW, Shah PH, Nencka AS, Sivaram Kaushik S, Potter HG. Off-resonance based assessment of metallic wear debris near total hip arthroplasty. Magn Reson Med 2017. [PMID: 28643347 DOI: 10.1002/mrm.26807] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The presence of metallic debris near total hip arthroplasty can have a significant impact on longitudinal patient management. Methods for magnetic resonance imaging-based quantification of metallic debris near painful total hip replacements are described and applied to cohorts of symptomatic and control subject cases. METHODS A combination of metal artifact reduction, off-resonance mapping, off-resonance background removal, and spatial clustering methods are utilized to quantify off-resonance signatures in cases of suspected metallosis. These methods are applied to a cohort of symptomatic hip arthroplasties composed of cobalt-chromium alloys. Magnetostatic simulations and theoretical principles are used to illuminate the potential sources of the measured off-resonance effects. Reported metrics from histological tissue assays extracted during surgical revision procedures are also correlated with the proposed magnetic resonance imaging-based quantification results. RESULTS The presented methods identified quantifiable metallosis signatures in more than 70% of the symptomatic and none of the control cases. Preliminary correlations of the MR data with direct histological evaluation of retrieved tissue samples indicate that the observed off-resonance effect may be related to tissue necrosis. CONCLUSIONS Magnetostatic simulations, theoretical principles, and preliminary histological trends suggest that disassociated cobalt is the source of the observed off-resonance signature. Magn Reson Med 79:1628-1637, 2018. © 2017 International Society for Magnetic Resonance in Medicine.
Collapse
Affiliation(s)
- Kevin M Koch
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew F Koff
- Division of Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA
| | - Thomas W Bauer
- Anatomic Pathology and Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Parina H Shah
- Division of Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA
| | - Andrew S Nencka
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - S Sivaram Kaushik
- MR Applications and Workflow, GE Healthcare, Milwaukee, Wisconsin, USA
| | - Hollis G Potter
- Division of Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA
| |
Collapse
|
27
|
Corrosion of Harrington rod in idiopathic scoliosis: long-term effects. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017. [PMID: 28624897 DOI: 10.1007/s00586-017-5183-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Metal implants have been used to treat adolescent idiopathic scoliosis since the 1960s. Only recently, however, it has the issue of metal-bone breakdown secondary to metal corrosion in situ come to light, raising concerns of possible long-term complications from the resulting metallosis and inflammation of spinal tissues. We present a case of a patient with neurological deficit, pain, and disability with Harrington rod in place for over 30 years, to bring attention to the issue of bio-corrosion of metal implants and its effect on human tissue. We call attention to the need for protocols to better diagnose and treat these patients. METHODS We provide a complete review of the history and clinical manifestations as well as serum metal, X-ray, and CT/myelogram test results. RESULTS A 52-year-old female with spinal fusion and Harrington rod presents with pain, lymphedema, disability, and neurological deficits including thoracic outlet syndrome, hyperreflexia, peripheral muscle weakness and atrophy, hypertonicity, Raynaud's phenomenon, and balance and gait abnormalities. Serum chromium levels were elevated (26.73 nmol). X-rays showed no evidence of rod breakdown. Serial X-rays can demonstrate subtle corrosive changes but were not available. Adhesive arachnoiditis was diagnosed via CT/myelogram. CONCLUSION We hypothesize that bio-corrosion is present in this case and that it is associated with intraspinal metallosis. Trauma secondary to a motor vehicle accident, as well as arachnoiditis, and their possible effects on this case are outlined. Challenges in proper diagnosis and management are discussed.
Collapse
|
28
|
Leyssens L, Vinck B, Van Der Straeten C, Wuyts F, Maes L. Cobalt toxicity in humans-A review of the potential sources and systemic health effects. Toxicology 2017; 387:43-56. [PMID: 28572025 DOI: 10.1016/j.tox.2017.05.015] [Citation(s) in RCA: 386] [Impact Index Per Article: 55.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/17/2017] [Accepted: 05/24/2017] [Indexed: 12/21/2022]
Abstract
Cobalt (Co) and its compounds are widely distributed in nature and are part of numerous anthropogenic activities. Although cobalt has a biologically necessary role as metal constituent of vitamin B12, excessive exposure has been shown to induce various adverse health effects. This review provides an extended overview of the possible Co sources and related intake routes, the detection and quantification methods for Co intake and the interpretation thereof, and the reported health effects. The Co sources were allocated to four exposure settings: occupational, environmental, dietary and medical exposure. Oral intake of Co supplements and internal exposure through metal-on-metal (MoM) hip implants deliver the highest systemic Co concentrations. The systemic health effects are characterized by a complex clinical syndrome, mainly including neurological (e.g. hearing and visual impairment), cardiovascular and endocrine deficits. Recently, a biokinetic model has been proposed to characterize the dose-response relationship and effects of chronic exposure. According to the model, health effects are unlikely to occur at blood Co concentrations under 300μg/l (100μg/l respecting a safety factor of 3) in healthy individuals, hematological and endocrine dysfunctions are the primary health endpoints, and chronic exposure to acceptable doses is not expected to pose considerable health hazards. However, toxic reactions at lower doses have been described in several cases of malfunctioning MoM hip implants, which may be explained by certain underlying pathologies that increase the individual susceptibility for Co-induced systemic toxicity. This may be associated with a decrease in Co bound to serum proteins and an increase in free ionic Co2+. As the latter is believed to be the primary toxic form, monitoring of the free fraction of Co2+ might be advisable for future risk assessment. Furthermore, future research should focus on longitudinal studies in the clinical setting of MoM hip implant patients to further elucidate the dose-response discrepancies.
Collapse
Affiliation(s)
- Laura Leyssens
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Bart Vinck
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium; Faculty of Humanities, University of Pretoria (South Africa), Department of Speech-Language Pathology and Audiology, Aula Theatre,University Road, Pretoria, 0001, South Africa.
| | - Catherine Van Der Straeten
- Faculty of Medicine, Imperial College London, Department of Surgery & Cancer, Musculoskeletal Sciences and Technology, Imperial College London, Charing Cross Campus,7L21 Lab Block, London SW7 2AZ, UK; Faculty of Medicine and Health Sciences, University of Ghent (Belgium), De Pintelaan 185, 9000 Ghent, Belgium.
| | - Floris Wuyts
- Antwerp University Research center for Equilibrium and Aerospace (AUREA), Department of Otorhinolaryngology, University Hospital Antwerp, Campus Groenenborger, Groenenborgerlaan 171, 2020 Antwerp, Belgium; Department of Biomedical Physics, University of Antwerp (Belgium), Campus Groenenborger, Groenenborgerlaan 171, 2020 Antwerp, Belgium.
| | - Leen Maes
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium; Clinical audiology department, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium.
| |
Collapse
|
29
|
Georgi JC, Sommer YL, Ward CD, Cheng PY, Jones RL, Caldwell KL. Biomonitoring method for the analysis of chromium and cobalt in human whole blood using inductively coupled plasma - kinetic energy discrimination - mass spectrometry (ICP-KED-MS). ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2017; 9:3464-3476. [PMID: 29201158 PMCID: PMC5709816 DOI: 10.1039/c7ay00430c] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The Centers for Disease Control and Prevention developed a biomonitoring method to rapidly and accurately quantify chromium and cobalt in human whole blood by ICP-MS. Many metal-on-metal hip implants which contain significant amounts of chromium and cobalt are susceptible to metal degradation. This method is used to gather population data about chromium and cobalt exposure of the U.S. population that does not include people that have metal-on-metal hip implants so that reference value can be established for a baseline level in blood. We evaluated parameters such as; helium gas flow rate, choice and composition of the diluent solution for sample preparation, and sample rinse time to determine the optimal conditions for analysis. The limits of detection for chromium and cobalt in blood were determined to be 0.41 and 0.06 μg/L, respectively. Method precision, accuracy, and recovery for this method were determined using quality control material created in-house and historical proficiency testing samples. We conducted experiments to determine if quantitative changes in the method parameters affect the results obtained by changing four parameters while analyzing human whole blood spiked with National Institute of Standard and Technology traceable materials: the dilution factor used during sample preparation, sample rinse time, diluent composition, and kinetic energy discrimination gas flow rate. The results at the increased and decreased levels for each parameter were statistically compared to the results obtained at the optimized parameters. We assessed the degree of reproducibility obtained under a variety of conditions and evaluated the method's robustness by analyzing the same set of proficiency testing samples by different analysts, on different instruments, with different reagents, and on different days. The short-term stability of chromium and cobalt in human blood samples stored at room temperature was monitored over a time period of 64 hours by diluting and analyzing samples at different time intervals. The stability of chromium and cobalt post-dilution was also evaluated over a period of 48 hours and at two storage temperatures (room temperature and refrigerated at 4°C). The results obtained during the stability studies showed that chromium and cobalt are stable in human blood for a period of 64 hours.
Collapse
Affiliation(s)
- Joaudimir Castro Georgi
- Inorganic & Radiation Analytical Toxicology Branch, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop F-50, Atlanta, GA 30341-3717
| | - Yuliya L Sommer
- Inorganic & Radiation Analytical Toxicology Branch, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop F-50, Atlanta, GA 30341-3717
| | - Cynthia D Ward
- Inorganic & Radiation Analytical Toxicology Branch, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop F-50, Atlanta, GA 30341-3717
| | - Po-Yung Cheng
- Inorganic & Radiation Analytical Toxicology Branch, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop F-50, Atlanta, GA 30341-3717
| | - Robert L Jones
- Inorganic & Radiation Analytical Toxicology Branch, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop F-50, Atlanta, GA 30341-3717
| | - Kathleen L Caldwell
- Inorganic & Radiation Analytical Toxicology Branch, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop F-50, Atlanta, GA 30341-3717
| |
Collapse
|
30
|
Gillam MH, Pratt NL, Inacio MCS, Roughead EE, Shakib S, Nicholls SJ, Graves SE. Heart failure after conventional metal-on-metal hip replacements. Acta Orthop 2017; 88:2-9. [PMID: 27759468 PMCID: PMC5251259 DOI: 10.1080/17453674.2016.1246276] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - It is unclear whether metal particles and ions produced by mechanical wear and corrosion of hip prostheses with metal-on-metal (MoM) bearings have systemic adverse effects on health. We compared the risk of heart failure in patients with conventional MoM total hip arthroplasty (THA) and in those with metal-on-polyethylene (MoP) THA. Patients and methods - We conducted a retrospective cohort study using data from the Australian Government Department of Veterans' Affairs health claims database on patients who received conventional THA for osteoarthritis between 2004 and 2012. The MoM THAs were classified into groups: Articular Surface Replacement (ASR) XL Acetabular System, other large-head (LH) (> 32 mm) MoM, and small-head (SH) (≤ 32 mm) MoM. The primary outcome was hospitalization for heart failure after THA. Results - 4,019 patients with no history of heart failure were included (56% women). Men with an ASR XL THA had a higher rate of hospitalization for heart failure than men with MoP THA (hazard ratio (HR) = 3.2, 95% CI: 1.6-6.5). No statistically significant difference in the rate of heart failure was found with the other LH MoM or SH MoM compared to MoP in men. There was no statistically significant difference in heart failure rate between exposure groups in women. Interpretation - An association between ASR XL and hospitalization for heart failure was found in men. While causality between ASR XL and heart failure could not be established in this study, it highlights an urgent need for further studies to investigate the possibility of systemic effects associated with MoM THA.
Collapse
Affiliation(s)
- Marianne H Gillam
- School of Pharmacy and Medical Sciences, The Quality Use of Medicines and Pharmacy Research Centre, University of South Australia,Correspondence:
| | - Nicole L Pratt
- School of Pharmacy and Medical Sciences, The Quality Use of Medicines and Pharmacy Research Centre, University of South Australia
| | - Maria C S Inacio
- School of Pharmacy and Medical Sciences, The Quality Use of Medicines and Pharmacy Research Centre, University of South Australia
| | - Elizabeth E Roughead
- School of Pharmacy and Medical Sciences, The Quality Use of Medicines and Pharmacy Research Centre, University of South Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, School of Medicine, University of Adelaide
| | - Stephen J Nicholls
- Department of Medicine, University of Adelaide and South Australian Health and Medical Research Institute, University of Adelaide
| | - Stephen E Graves
- Flinders University School of Medicine, Flinders University, Adelaide and Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| |
Collapse
|
31
|
Abstract
Cobalt can cause a distinctive, rapidly progressive and reversible depression of cardiac systolic function, which is readily distinguished from other causes of cardiomyopathy. Patients present with the subacute onset of severe heart failure, which is accompanied by hypotension and cyanosis, pericardial effusion, low voltage on the electrocardiogram, marked elevation of serum enzymes, and lactic acidosis. They typically have a history of lethargy, anorexia, and weight loss in the months preceding the illness and exhibit other evidence of cobalt’s effects on the body (eg, polycythemia and goiter). The course of cobalt-related cardiomyopathy may be progressive and fatal, but those who survive and cease exposure generally demonstrate complete resolution of symptoms and recovery of cardiac function. Patients presenting with rapid onset of cardiomyopathy, who also exhibit polycythemia, pericardial effusion, or goiter should be evaluated for cobalt exposure. Exposure can be confirmed by the measurement of cobalt in the serum, but serum levels of the ion are not reliably predictive of clinical cardiotoxicity. The clinical emergence of cobalt cardiomyopathy seems to require the coexistence of one or more cofactors, particularly a low-protein diet, thiamine deficiency, alcoholism, and hypothyroidism. As the medicinal use of cobalt has waned and measures to reduce industrial exposure have been implemented, subacute cobalt-related cardiomyopathy had become rare. However, reports describing classical features of the disease have recently surged among patients with a malfunctioning cobalt-alloy hip prosthesis.
Collapse
Affiliation(s)
- Milton Packer
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX
| |
Collapse
|
32
|
Bolea-Fernandez E, Phan K, Balcaen L, Resano M, Vanhaecke F. Determination of ultra-trace amounts of prosthesis-related metals in whole blood using volumetric absorptive micro-sampling and tandem ICP – Mass spectrometry. Anal Chim Acta 2016; 941:1-9. [DOI: 10.1016/j.aca.2016.08.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 12/20/2022]
|
33
|
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]
|
34
|
Harrington CF, McKibbin C, Rahanu M, Langton D, Taylor A. Measurement of titanium in hip-replacement patients by inductively coupled plasma optical emission spectroscopy. Ann Clin Biochem 2016; 54:362-369. [DOI: 10.1177/0004563216662292] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Patients with metal-on-metal hip replacements require testing for cobalt and chromium. There may also be a need to test for titanium, which is used in the construction of the femoral stem in total hip replacements. It is not possible to use quadrupole inductively coupled plasma mass spectrometry due to interferences. Methods Titanium was measured using inductively coupled plasma optical emission spectroscopy using the emission line at 336.1 nm and Y (internal standard) at 371.0 nm. Internal quality control materials were prepared for blood and serum and concentrations assigned using a sector field-inductively coupled plasma mass spectrometer. A candidate whole blood certified reference material was also evaluated. Results The method had detection and quantitation limits of 0.6 and 1.9 µg/L, respectively. The respective bias (%) and measurement uncertainty ( U) (k = 2) were 3.3% and 2.0 µg/L (serum) and − 1.0% and 1.4 µg/L (whole blood). The respective repeatability and intermediate precision (%) were 5.1% and 10.9% (serum) and 2.4% and 8.6% (whole blood). The concentration of titanium was determined in patients’ samples, serum (median = 2.4 µg/L, n = 897) and whole blood (median = 2.4 µg/L, n = 189). Serum is recommended for monitoring titanium in patients, since the concentration is higher than in whole blood and the matrix less problematic. In hip fluid samples, the concentrations were much higher (mean 58.5 µg/L, median 5.1 µg/L, n = 83). Conclusions A method based on inductively coupled plasma optical emission spectroscopy was developed and validated for measuring titanium in clinical samples.
Collapse
Affiliation(s)
- Chris F Harrington
- Supra-Regional Assay Service (SAS), Trace Element Centre, Surrey Research Park, Guildford, Surrey, UK
| | - Craig McKibbin
- Supra-Regional Assay Service (SAS), Trace Element Centre, Surrey Research Park, Guildford, Surrey, UK
| | - Monika Rahanu
- Supra-Regional Assay Service (SAS), Trace Element Centre, Surrey Research Park, Guildford, Surrey, UK
| | - David Langton
- University Hospital of North Tees, Stockton, Cleveland, UK
| | - Andrew Taylor
- Supra-Regional Assay Service (SAS), Trace Element Centre, Surrey Research Park, Guildford, Surrey, UK
| |
Collapse
|
35
|
Lessons learnt from metal-on-metal hip arthroplasties will lead to safer innovation for all medical devices. Hip Int 2016; 25:347-54. [PMID: 26165359 DOI: 10.5301/hipint.5000275] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2015] [Indexed: 02/06/2023]
Abstract
Metal-on-metal bearings were re-popularised in the late 1990s with the introduction of modern hip resurfacing. Large diameter (LD) metal-on-metal (MoM) hips became more prevalent and have been the least successful group of hip implants ever used. They were rapidly adopted from 2004 until the British Hip Society stopped their use in 2012. Well functioning MoM hip results (including the BHR and Metasul) are hidden in the mire of poor results from the group of all MoM bearings.We have reviewed what happened and we make 3 observations. Firstly, collaboration between surgeons and then between surgeons and other disciplines, first identified and then solved the clinical management problems. Secondly, the problems with MoM hips occurred because hip simulation was inadequate at predicting performance in patients. They gave no indications of the biological effects of wear in the human environment. Lastly, retrieval of failed implants was essential to understanding why failure occurred.These lessons must never be forgotten and must form the basis by which new or altered implants are introduced and how they should be monitored. This will enable safer innovation for patients, surgeons and manufacturers. The problems with MoM hips will not have been in vain.
Collapse
|
36
|
SHANKAR S, NITHYAPRAKASH R. PREDICTING THE WEAR OF SOFT-ON-HARD BEARING COUPLES FOR HUMAN HIP PROSTHESIS USING FINITE ELEMENT CONCEPTS. J MECH MED BIOL 2016. [DOI: 10.1142/s0219519416500202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Wear of bearing couples is one of the major concerns in artificial hip implantation. To minimize the wear of hip bearing surfaces, several new materials have been introduced and tested including metal-on-metal, ceramic-on-ceramic and hard-on-hard combinations. The present study involves prediction of wear on ultra-high molecular weight polyethylene (UHMWPE) cup against Co–Cr, alumina and zirconia femoral head by applying the three-dimensional (3D) physiological loads as well as angular motions on these bearing couples to calculate the contact pressure using finite element concepts. The linear and volumetric wear of bearing surfaces increase with increase in gait cycles. Overall, the Zirconia–UHMWPE combination showed least wear, when compared with Alumina–UHMWPE and Co–Cr–UHMWPE combinations. The present study also revealed that the Zirconia–UHMWPE combinations showed less volumetric wear than the Alumina–Alumina bearing which is at present used in artificial hip resurfacements.
Collapse
Affiliation(s)
- S. SHANKAR
- Department of Mechatronics Engineering, Kongu Engineering College, Erode, India
| | - R. NITHYAPRAKASH
- Department of Mechanical Engineering, Kongu Engineering College, Erode, India
| |
Collapse
|
37
|
Zywiel MG, Cherian JJ, Banerjee S, Cheung AC, Wong F, Butany J, Gilbert C, Overgaard C, Syed K, Jacobs JJ, Mont MA. Systemic cobalt toxicity from total hip arthroplasties. Bone Joint J 2016; 98-B:14-20. [PMID: 26733510 DOI: 10.1302/0301-620x.98b1.36712] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
As adverse events related to metal on metal hip arthroplasty have been better understood, there has been increased interest in toxicity related to the high circulating levels of cobalt ions. However, distinguishing true toxicity from benign elevations in cobalt levels can be challenging. The purpose of this review is to examine the use of cobalt alloys in total hip arthroplasty, to review the methods of measuring circulating cobalt levels, to define a level of cobalt which is considered pathological and to review the pathophysiology, risk factors and treatment of cobalt toxicity. To the best of our knowledge, there are 18 published cases where cobalt metal ion toxicity has been attributed to the use of cobalt-chromium alloys in hip arthroplasty. Of these cases, the great majority reported systemic toxic reactions at serum cobalt levels more than 100 μg/L. This review highlights some of the clinical features of cobalt toxicity, with the goal that early awareness may decrease the risk factors for the development of cobalt toxicity and/or reduce its severity. Take home message: Severe adverse events can arise from the release of cobalt from metal-on-metal arthroplasties, and as such, orthopaedic surgeons should not only be aware of the presenting problems, but also have the knowledge to treat appropriately. Cite this article: Bone Joint J 2016;98-B:14–20.
Collapse
Affiliation(s)
- M. G. Zywiel
- University of Toronto, 100
College Street Room 302, Toronto, Ontario, M5G
1L5, Canada
| | - J. J. Cherian
- Philadelphia College of Osteopathic Medicine, 4190
City Line Ave, Philadelphia, PA
19131, USA
| | - S. Banerjee
- Sinai Hospital of Baltimore, 2401
West Belvedere Avenue, Baltimore, MD 21215, USA
| | - A. C. Cheung
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - F. Wong
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - J. Butany
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - C. Gilbert
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - C. Overgaard
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - K. Syed
- University of Toronto, 100
College Street Room 302, Toronto, Ontario, M5G
1L5, Canada
| | - J. J. Jacobs
- Rush
University, 1611 W. Harrison St., Suite
400, Chicago, IL, 60612, USA
| | - M. A. Mont
- Sinai Hospital of Baltimore, 2401
West Belvedere Avenue, Baltimore, MD 21215, USA
| |
Collapse
|
38
|
In Vitro Analyses of the Toxicity, Immunological, and Gene Expression Effects of Cobalt-Chromium Alloy Wear Debris and Co Ions Derived from Metal-on-Metal Hip Implants. LUBRICANTS 2015. [DOI: 10.3390/lubricants3030539] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
39
|
Loeschner K, Harrington CF, Kearney JL, Langton DJ, Larsen EH. Feasibility of asymmetric flow field-flow fractionation coupled to ICP-MS for the characterization of wear metal particles and metalloproteins in biofluids from hip replacement patients. Anal Bioanal Chem 2015; 407:4541-54. [DOI: 10.1007/s00216-015-8631-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/04/2015] [Accepted: 03/10/2015] [Indexed: 12/19/2022]
|
40
|
Self-reported neurological clinical manifestations of metal toxicity in metal-on-metal hip arthroplasty. Hip Int 2014; 24:568-74. [PMID: 25096449 DOI: 10.5301/hipint.5000179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2014] [Indexed: 02/04/2023]
Abstract
Adverse reactions to metal particle debris have been increasingly reported as a complication following large head metal-on-metal (MoM) hip arthroplasty. Elevated metal ion levels are a cause for concern. The aim of this study is to evaluate whether exposure to cobalt is associated with patient characteristics and symptoms of neuropathy, representing nervous system dysfunction. A cross-sectional study was conducted comparing patients with a MoM total hip arthroplasty and patients with a conventional hip arthroplasty. They received three questionnaires, one to assess neurotoxic complaints and two standardised self-administered questionnaires to identify symptoms that are suggestive of peripheral neuropathy. Current and historical data were available for whole blood cobalt levels in all patients. We analysed potential predictive factors for cobalt based on five different cut-off levels (0-2, 2-4, 4-10, 10-20, >20 µg/L). We performed 723 MoM total hip arthroplasties in 643 patients in our clinic. The response rate was 89%. Male-female ratio was 236/280, median age 63.6 years (30-72) with a mean follow-up of 50.6 months (20-86). We also sent the questionnaires to 98 patients in the control group. An increase in the incidence of reported symptoms was not consistent with higher serum cobalt levels. Female gender was the only consistent predictive factor for serum cobalt at different cobalt cut-off levels in the multivariate analysis. The study population did not show an increase in reported symptoms with elevated cobalt levels. Neurotoxic symptoms and whole blood cobalt levels did not show a consistent relationship with different dichotomised levels of cobalt exposure.
Collapse
|
41
|
Morton JM, Rahn KA, Shugart RM, Wojdyla JM. Does mechanical filtration of intraoperative cell salvage effectively remove titanium debris generated during instrumented spinal surgery? An in vitro analysis. Spine J 2014; 14:3011-7. [PMID: 25011093 DOI: 10.1016/j.spinee.2014.06.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 05/14/2014] [Accepted: 06/30/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Instrumented fusion of the spine is a surgery commonly performed to stabilize vertebrae causing pain and to correct anatomic deformities. Such surgery can create substantial blood loss. Autotransfusion is a means to limit homologous blood transfusion in this setting. However, a dilemma is created when the high-speed drill used for bone removal comes in contact with implanted titanium spinal hardware. A clinician at this point is forced to decide between two options: to discontinue autotransfusion to avoid the potential transfusion of titanium fragments while risking blood loss and the need for homologous transfusion or to continue autotransfusion while risking transfusion of titanium fragments back into circulation. PURPOSE To conclusively identify whether titanium fragments created by a high-speed drill are able to pass through standard autotransfusion microaggregate blood filters. STUDY DESIGN A positive and negatively controlled experiment with blinded sample analysis. OUTCOMES MEASURES The presence or absence of titanium alloy on a filter with detection by energy-dispersive X-ray spectroscopy (EDX). METHODS A mock autotransfusion setup was devised for in vitro filtering. Six investigational and two control experiments were conducted. Titanium fragments generated by a high-speed drill were aspirated with saline and filtered with standard autotransfusion reservoirs and microaggregate blood filters. A final filter with a 1-μm pore size was placed distal to the blood filters. After filtration was complete, this final filter was analyzed using EDX. RESULTS The presence of titanium was confirmed by EDX on five of six investigational filters. The positive and negative control filters were analyzed by EDX and tested positive and negative, respectively, for titanium. CONCLUSIONS Standard 40 μm reservoir and blood microaggregate filters do not eliminate the smallest fragments of titanium generated by contact between a high-speed drill and a titanium hardware. The mass of titanium able to elude filtration is very small. The impact of transfusing blood contaminated with such a small mass of titanium is not known.
Collapse
Affiliation(s)
- John M Morton
- Lutheran Medical Group, 7910 W. Jefferson Ave., Suite 102, Fort Wayne, IN, 46804 USA.
| | - Kevin A Rahn
- Fort Wayne Orthopedics, 7601 W Jefferson Blvd, Fort Wayne, IN 46804 USA
| | - Robert M Shugart
- Fort Wayne Orthopedics, 7601 W Jefferson Blvd, Fort Wayne, IN 46804 USA
| | - Jacob M Wojdyla
- Rush University, College of Health Sciences, Department of Perfusion Technology. Armour Academic Center, 600 S. Paulina Street, Suite 1021, Chicago, IL 60612 USA
| |
Collapse
|
42
|
Monnot AD, Christian WV, Paustenbach DJ, Finley BL. Correlation of blood Cr(III) and adverse health effects: Application of PBPK modeling to determine non-toxic blood concentrations. Crit Rev Toxicol 2014; 44:618-37. [DOI: 10.3109/10408444.2014.926472] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
43
|
Molecular analysis of chromium and cobalt-related toxicity. Sci Rep 2014; 4:5729. [PMID: 25034144 PMCID: PMC4103093 DOI: 10.1038/srep05729] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 06/27/2014] [Indexed: 12/12/2022] Open
Abstract
Occupational and environmental exposure to Co and Cr has been previously linked to a wide array of inflammatory and degenerative conditions and cancer. Recently, significant health concerns have been raised by the high levels of Cr and Co ions and corrosion products released by biomedical implants. Herein, we set to analyze the biological responses associated with Co and Cr toxicity. Histological, ultrastructural, and elemental analysis, performed on Cr and Co exposed patients reveal the presence of corrosion products, metallic wear debris and metal ions at varying concentrations. Metallic ions and corrosion products were also generated in vitro following macrophage phagocytosis of metal alloys. Ex vivo redox proteomic mapped several oxidatively damaged proteins by Cr(III) and Co(II)-induced Fenton reaction. Importantly, a positive correlation between the tissue amounts of Cr(III) and Co(II) ions and tissue oxidative damage was observed. Immobilized- Cr(III) and Co(II) affinity chromatography indicated that metal ions can also directly bind to several metallo and non-metalloproteins and, as demonstrated for aldolase and catalase, induce loss of their biological function. Altogether, our analysis reveals several biological mechanisms leading to tissue damage, necrosis, and inflammation in patients with Cr and Co-associated adverse local tissue reactions.
Collapse
|
44
|
Hart AJ, Sabah SA, Sampson B, Skinner JA, Powell JJ, Palla L, Pajamäki KJJ, Puolakka T, Reito A, Eskelinen A. Surveillance of Patients with Metal-on-Metal Hip Resurfacing and Total Hip Prostheses: A Prospective Cohort Study to Investigate the Relationship Between Blood Metal Ion Levels and Implant Failure. J Bone Joint Surg Am 2014; 96:1091-1099. [PMID: 24990974 DOI: 10.2106/jbjs.m.00957] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We designed a prospective, single-center study to assess whether blood metal ion levels could predict implant failure in patients managed with unilateral metal-on-metal hip resurfacing or total hip arthroplasty. METHODS Five hundred and ninety-seven patients who had received unilateral Articular Surface Replacement prostheses at least twelve months earlier were recruited. Blood metal ion levels were compared between the group of patients with failed implants and the group with non-failed implants. Implant failure was defined as prostheses associated with revision, an intention to revise, or poor patient-reported hip function (Oxford Hip Score, <31 of 48). Specificity, sensitivity, area under the curve, positive and negative predictive values, and odds ratios were calculated. Logistic regression analysis was used to identify other risk factors for implant failure. RESULTS Patients with failed arthroplasty had significantly higher blood cobalt and chromium ion levels than did patients with non-failed arthroplasty (p < 0.01). Blood cobalt ion levels were disproportionately raised in patients with failed total hip arthroplasty (8.2 μg/L) compared with patients with failed hip resurfacing (2.5 μg/L) (p = 0.018). Blood chromium ion levels were not significantly different in patients with failed total hip arthroplasty and failed hip resurfacing (p = 0.058). The maximum value of either metal ion had good discriminant ability to predict implant failure (area under the curve, 0.76). A 7-μg/L cutoff had a positive predictive value of 0.75 (95% confidence interval, 0.66 to 0.82) and a negative predictive value of 0.82 (95% confidence interval, 0.78 to 0.86). In patients managed with total hip arthroplasty, for each increase of 1 μg/L there was a 23% (p < 0.001) increase in the odds of them being in the failed group. For patients managed with hip resurfacing, the increase in odds was 5% (p < 0.001). CONCLUSIONS Raised levels of blood metal ions were associated with failed metal-on-metal hip resurfacings and total hip arthroplasties. A threshold level of 7 μg/L had inadequate sensitivity to be used in isolation as a screening test for implant failure, but it provided nearly optimal misclassification rates. No level had a perfect positive predictive value, and so we discourage surgeons from performing revision surgery based on blood metal ion levels alone. Levels of cobalt ions were raised out of proportion to levels of chromium ions in failed total hip arthroplasty and may reflect a different mechanism for metal ion generation. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- A J Hart
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London HA7 4LP, United Kingdom. E-mail address for A.J. Hart: . E-mail address for S.A. Sabah: . E-mail address for J.A. Skinner:
| | - S A Sabah
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London HA7 4LP, United Kingdom. E-mail address for A.J. Hart: . E-mail address for S.A. Sabah: . E-mail address for J.A. Skinner:
| | - B Sampson
- Department of Clinical Biochemistry, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, W6 8RF, United Kingdom. E-mail address:
| | - J A Skinner
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London HA7 4LP, United Kingdom. E-mail address for A.J. Hart: . E-mail address for S.A. Sabah: . E-mail address for J.A. Skinner:
| | - J J Powell
- MRC Centre for Human Nutrition Research, 120 Fulbourn Road, Cambridge CB1 9NL, United Kingdom. E-mail address:
| | - L Palla
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom. E-mail address:
| | - K J J Pajamäki
- Coxa Hospital for Joint Replacement, P.O. Box 652, 33101 Tampere, Finland. E-mail address for K.J.J. Pajamäki: . E-mail address for T. Puolakka: . E-mail address for A. Reito: . E-mail address for A. Eskelinen:
| | - T Puolakka
- Coxa Hospital for Joint Replacement, P.O. Box 652, 33101 Tampere, Finland. E-mail address for K.J.J. Pajamäki: . E-mail address for T. Puolakka: . E-mail address for A. Reito: . E-mail address for A. Eskelinen:
| | - A Reito
- Coxa Hospital for Joint Replacement, P.O. Box 652, 33101 Tampere, Finland. E-mail address for K.J.J. Pajamäki: . E-mail address for T. Puolakka: . E-mail address for A. Reito: . E-mail address for A. Eskelinen:
| | - A Eskelinen
- Coxa Hospital for Joint Replacement, P.O. Box 652, 33101 Tampere, Finland. E-mail address for K.J.J. Pajamäki: . E-mail address for T. Puolakka: . E-mail address for A. Reito: . E-mail address for A. Eskelinen:
| |
Collapse
|
45
|
Durrani SK, Noble PC, Sampson B, Panetta T, Liddle AD, Sabah SA, Chan NK, Skinner JA, Hart AJ. Changes in blood ion levels after removal of metal-on-metal hip replacements: 16 patients followed for 0-12 months. Acta Orthop 2014; 85:259-65. [PMID: 24758321 PMCID: PMC4062792 DOI: 10.3109/17453674.2014.913223] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE In patients with metal-on-metal (MoM) hip prostheses, pain and joint effusions may be associated with elevated blood levels of cobalt and chromium ions. Since little is known about the kinetics of metal ion clearance from the body and the rate of resolution of elevated blood ion levels, we examined the time course of cobalt and chromium ion levels after revision of MoM hip replacements. PATIENTS AND METHODS We included 16 patients (13 female) who underwent revision of a painful MoM hip (large diameter, modern bearing) without fracture or infection, and who had a minimum of 4 blood metal ion measurements over an average period of 6.1 (0-12) months after revision. RESULTS Average blood ion concentrations at the time of revision were 22 ppb for chromium and 43 ppb for cobalt. The change in ion levels after revision surgery varied extensively between patients. In many cases, over the second and third months after revision surgery ion levels decreased to 50% of the values measured at revision. Decay of chromium levels occurred more slowly than decay of cobalt levels, with a 9% lag in return to normal levels. The rate of decay of both metals followed second-order (exponential) kinetics more closely than first-order (linear) kinetics. INTERPRETATION The elimination of cobalt and chromium from the blood of patients who have undergone revision of painful MoM hip arthroplasties follows an exponential decay curve with a half-life of approximately 50 days. Elevated blood levels of cobalt and chromium ions can persist for at least 1 year after revision, especially in patients with high levels of exposure.
Collapse
Affiliation(s)
| | - Philip C Noble
- Institute of Orthopedic Research and Education,Baylor College of Medicine, Houston, TX, USA
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Scientific Opinion on the risks to public health related to the presence of chromium in food and drinking water. EFSA J 2014. [DOI: 10.2903/j.efsa.2014.3595] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
|
47
|
Abstract
Increasing data are available describing risk factors for the development of local and systemic adverse events following operations using metal-on-metal (MoM) hip implants. The prevalence and clinical relevance of metal-associated problems are, however, still under debate. They can be influenced by type and position of implant as well as patient-specific factors. Patients with small MoM heads (maximum diameter 32 mm) and subgroups of resurfacing arthroplasty can achieve good long-term survival. The use of large head MoM implants (diameters greater than 36 mm), however, is currently not advised due to the unsatisfactory results.
Collapse
|
48
|
Devlin JJ, Pomerleau AC, Brent J, Morgan BW, Deitchman S, Schwartz M. Clinical features, testing, and management of patients with suspected prosthetic hip-associated cobalt toxicity: a systematic review of cases. J Med Toxicol 2013; 9:405-15. [PMID: 24222555 PMCID: PMC3846976 DOI: 10.1007/s13181-013-0320-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Safety concerns regarding cobalt-containing metal alloy hip prosthetics (Co-HP) have resulted in product recalls, a medical device alert, and issuance of guidance for clinicians. Recently, cases of suspected prosthetic hip-associated cobalt toxicity (PHACT) from Co-HP have been reported. Although little is known about suspected PHACT, these patients may be referred to medical toxicologists for evaluation and management recommendations. We searched MEDLINE, EMBASE, and unpublished abstracts from toxicology scientific meetings for references relevant to PHACT. Authors independently screened publications for inclusion criteria: publication in English, human study population, subject(s) are symptomatic (except for isolated hip pain), and cobalt values in any matrix (blood, serum, urine, CSF, synovial fluid) available for review. Data from 10 cases are reviewed. Patients with suspected PHACT had findings consistent with cobalt toxicity, including thyroid, cardiac, and neurologic dysfunction. Signs and symptoms appeared between 3 and 72 months after arthroplasty (median 19 months). Neurologic symptoms were most common. Ancillary testing varied considerably. All patients had elevated cobalt levels in one or more matrices. Enhanced elimination was attempted in 27 % of patients. At this time, the information currently available regarding patients with suspected PHACT is inadequate to guide clinical decision making. No consensus has been reached regarding the management of Co-HP patients with systemic symptoms. Indications for chelation have not been established and require further study. Improved case definitions, improved surveillance, and controlled studies are needed to elucidate the scope of this problem and guide future investigations.
Collapse
Affiliation(s)
- John J Devlin
- Georgia Poison Center, 50 Hurt Plaza, Suite 600, Atlanta, GA, 30303, USA,
| | | | | | | | | | | |
Collapse
|
49
|
Paustenbach DJ, Galbraith DA, Finley BL. Interpreting cobalt blood concentrations in hip implant patients. Clin Toxicol (Phila) 2013; 52:98-112. [DOI: 10.3109/15563650.2013.857024] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
50
|
Beraudi A, Catalani S, Montesi M, Stea S, Sudanese A, Apostoli P, Toni A. Detection of cobalt in synovial fluid from metal-on-metal hip prosthesis: correlation with the ion haematic level. Biomarkers 2013; 18:699-705. [PMID: 24134776 DOI: 10.3109/1354750x.2013.846413] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Hip replacement with large metal-on-metal (MoM) coupling has recently been under attention for its metal ions release, inducing several disorders. Since the blood level toxicity threshold for cobalt is known, the aim of this work is to determine whether Co serum and blood levels correlate with the synovial fluid level. Beside this, the synovial fluid Co from patients without prosthesis has also been measured. Co has been determined in 54 samples (32 unilateral MoM and 22 controls) with inductively coupled plasma mass spectrometry in the three matrices. In the prosthesized group, cobalt was significantly higher compared with controls and in the synovial fluid it strongly correlated with whole blood Co (p = 0.847) and serum (p = 0.855). Moreover, the Co levels into whole blood and serum were significantly different. In conclusion, haematic Co concentration correctly reflects Co local level.
Collapse
Affiliation(s)
- Alina Beraudi
- Medical Technology Laboratory, PROMETEO Laboratory, Rizzoli RIT Department-Research, Innovation & Technology, Rizzoli Orthopaedic Institute , Bologna , Italy
| | | | | | | | | | | | | |
Collapse
|