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Zhong Q, Pan X, Chen Y, Lian Q, Gao J, Xu Y, Wang J, Shi Z, Cheng H. Prosthetic Metals: Release, Metabolism and Toxicity. Int J Nanomedicine 2024; 19:5245-5267. [PMID: 38855732 PMCID: PMC11162637 DOI: 10.2147/ijn.s459255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/13/2024] [Indexed: 06/11/2024] Open
Abstract
The development of metallic joint prostheses has been ongoing for more than a century alongside advancements in hip and knee arthroplasty. Among the materials utilized, the Cobalt-Chromium-Molybdenum (Co-Cr-Mo) and Titanium-Aluminum-Vanadium (Ti-Al-V) alloys are predominant in joint prosthesis construction, predominantly due to their commendable biocompatibility, mechanical strength, and corrosion resistance. Nonetheless, over time, the physical wear, electrochemical corrosion, and inflammation induced by these alloys that occur post-implantation can cause the release of various metallic components. The released metals can then flow and metabolize in vivo, subsequently causing potential local or systemic harm. This review first details joint prosthesis development and acknowledges the release of prosthetic metals. Second, we outline the metallic concentration, biodistribution, and elimination pathways of the released prosthetic metals. Lastly, we discuss the possible organ, cellular, critical biomolecules, and significant signaling pathway toxicities and adverse effects that arise from exposure to these metals.
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Affiliation(s)
- Qiang Zhong
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Xin Pan
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Yuhang Chen
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Qiang Lian
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Jian Gao
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Yixin Xu
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Jian Wang
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Zhanjun Shi
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Hao Cheng
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
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Freund SS, Thorn APJ, Puri A, Petersen MM, Baad-Hansen T. Elevated cobalt levels in metal-on-polyethylene knee megaprostheses: a prospective 1-year cohort study of 56 patients with hip and knee megaprostheses. Acta Orthop 2024; 95:174-179. [PMID: 38629902 PMCID: PMC11022749 DOI: 10.2340/17453674.2024.40502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/13/2023] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND AND PURPOSE Concerns have emerged regarding elevated levels of cobalt and chromium in patients with metal-on-metal megaprostheses. This prospective study aims to identify systemic cobalt and chromium levels in metal-on-polyethylene knee and hip megaprostheses and their associations with other factors. METHODS 56 patients underwent knee or hip megaprosthesis surgery at 2 sarcoma centers. Serum cobalt and chromium levels were measured preoperatively and thrice within the first year using inductively coupled plasma mass spectrometry. RESULTS A statistically significant difference in serum cobalt levels (1.4 ppb; 95% confidence interval [CI] 0.0-3.3) was observed 1 year after knee megaprosthesis surgery compared with preoperative levels. In contrast no difference in chromium levels was observed after 1 year compared with preoperative levels (0.05 ppb; CI 0.0-0.8). An association between younger age, higher eGFR, and increased cobalt levels was observed. No significant correlations were found between ion levels and resection length or the number of modular connections. CONCLUSION We found elevated serum ion levels in metal-on-polyethylene knee megaprostheses in contrast to metal-on-polyethylene hip megaprostheses. Furthermore, a positive correlation between cobalt and chromium levels, and between cobalt and eGFR was identified, along with a negative correlation between cobalt and age. This study highlights the importance of monitoring systemic cobalt and chromium levels in patients with megaprostheses.
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Affiliation(s)
| | - Andrea Pohly Jeppesen Thorn
- Musculoskeletal Tumor Section of the Department of Orthopedic Surgery, Rigshospitalet - University of Copenhagen, Denmark
| | - Ajay Puri
- Orthopedic Oncology, Tata Memorial Centre, HBNI, Mumbai, India
| | - Michael Mørk Petersen
- Musculoskeletal Tumor Section of the Department of Orthopedic Surgery, Rigshospitalet - University of Copenhagen, Denmark
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Gómez-Álvarez J, Miranda I, Álvarez-Llanas A, Lisón JF, Bosch-Morell F, Doménech J. Influence of Physical Activity and Cup Orientation on Metal Ion Release and Oxidative Stress in Metal-on-Metal and Ceramic-on-Metal Total Hip Arthroplasty. J Clin Med 2024; 13:527. [PMID: 38256664 PMCID: PMC10816639 DOI: 10.3390/jcm13020527] [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: 12/04/2023] [Revised: 12/30/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Metal-on-metal (M-M) total hip arthroplasty (THA) has shown adverse reactions to metal debris, abnormal soft-tissue reactions, and high blood metal ion levels. This study aims to: (1) assess whether the toxicity of high levels of ions is related to altered oxidative stress and (2) evaluate tribological factors related to increased blood levels of chromium (Cr) and cobalt (Co) ions. METHODS A cross-sectional analytical descriptive study was conducted on 75 patients. A total of 25 underwent M-M THA, 25 ceramic-on-metal (C-M) THA, and 25 were on the THA waiting list. Ion metallic levels in blood, oxidative stress, physical activity, and implant position were compared. RESULTS In the M-M group, Co and Cr levels were significantly higher than those found in the C-M group and the control group (p < 0.01). We found no differences in terms of oxidative stress between the groups. Also, we did not find a correlation between metal blood levels and oxidative stress indicators, the physical activity of the patients or the position of the implants between groups. CONCLUSIONS The use of M-M bearing surfaces in THA raises the levels of metals in the blood without modifying oxidative stress regardless of the physical activity levels of the patients. Therefore, although patients with M-M bearings require close monitoring, it does not seem necessary to recommend the restriction of physical activity in patients with M-M or C-M arthroplasties.
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Affiliation(s)
- Jorge Gómez-Álvarez
- Department of Orthopedic Surgery, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
| | - Ignacio Miranda
- Department of Orthopedic Surgery, Hospital Arnau de Vilanova, 46015 Valencia, Spain
- Faculty of Health Sciences, Universidad Católica de Valencia, 46001 Valencia, Spain
| | - Alejandro Álvarez-Llanas
- Department of Orthopedic Surgery, Hospital Arnau de Vilanova, 46015 Valencia, Spain
- Faculty of Health Sciences, Universidad Católica de Valencia, 46001 Valencia, Spain
| | - Juan F. Lisón
- Department of Biomedical Sciences, Faculty of Health Sciences, University CEU Cardenal Herrera, 46115 Alfara del Patriarca, Spain; (J.F.L.); (F.B.-M.)
- CIBER de Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Francisco Bosch-Morell
- Department of Biomedical Sciences, Faculty of Health Sciences, University CEU Cardenal Herrera, 46115 Alfara del Patriarca, Spain; (J.F.L.); (F.B.-M.)
| | - Julio Doménech
- Department of Orthopedic Surgery, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
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Haddad FS. Looking ahead to autumn. Bone Joint J 2023; 105-B:943-945. [PMID: 37652451 DOI: 10.1302/0301-620x.105b9.bjj-2023-0780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Fares S Haddad
- Princess Grace Hospital, London, UK
- University College London Hospitals and The NIHR Biomedical Research Centre at UCLH, London, UK
- The Bone & Joint Journal , London, UK
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Oxblom A, Hedlund H, Itayem R, Felländer-Tsai L, Vidgren M, Rolfson O, Brismar H. Careful patient selection together with optimal implant positioning may reduce but does not eliminate the risk of elevated serum cobalt and chrome levels following metal-on-metal hip resurfacing. Hip Int 2023; 33:872-879. [PMID: 36314413 PMCID: PMC10486161 DOI: 10.1177/11207000221124302] [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: 02/02/2022] [Accepted: 07/31/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Elevated serum chrome (sCr) and cobalt (sCo) concentrations are associated with local tissue adverse reactions to metal debris following metal-on-metal hip resurfacing (MoM-HR). Serum metal ions <2 µg/l are probably of little clinical relevance and a pragmatic "safe" threshold <5 µg/l has been suggested.The primary aim of this study was to evaluate if a careful selection of patients combined with optimal implant positioning could eliminate cases with "unsafe" serum metal ion levels. A secondary aim was to study the association between different risk factors and having Co and/or Cr levels >5 µg/l. PATIENTS AND METHODS This is a retrospective, single-institution cohort study of 410 consecutive patients operated on with a Birmingham Hip Resurfacing (BHR) implant between 2001 and 2014. 288 of these had a unilateral MoM-HR, pelvic and true lateral radiographs, and a related sCo and sCr sample, and were included in the final analysis. They were allocated to either a presumed "optimal group" consisting of only men aged <60 years old, with femoral head component >48 mm diameter, and with a cup positioned within Lewinnek's safe zones, or a "suboptimal group" consisting of the remaining patients. Fisher's exact test and multiple logistic regression analyses were performed. RESULTS In the optimal group 48% (47/97) had serum metal ions >2 µg/l and 8% (8/97) >5 µg/l compared to 61% (116/191) and 18% (34/191) in the suboptimal group, p = 0.059 and p = 0.034 respectively. Acetabular cups with an anteversion <5 degrees had the highest odds ratio, 6.5 (95% CI, 3.0-14.3), of having sCo and sCr concentrations exceeding 5 µg/l. CONCLUSIONS A well oriented BHR acetabular component in a presumably "optimal" patient reduces the risk of having elevated serum metal ions but does not eliminate it. Insufficient cup anteversion seems to be the strongest associated factor of elevated serum metals.
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Affiliation(s)
- Alexander Oxblom
- Division of Orthopaedics and Biotechnology, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Department of Orthopaedics, VO KOU, Sodertalje Hospital, Sodertalje, Sweden
| | - Håkan Hedlund
- Division of Orthopaedics and Biotechnology, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Department of Orthopaedics, Visby Hospital, Visby, Sweden
| | - Raed Itayem
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy University of Gothenburg, Sweden
| | - Li Felländer-Tsai
- Division of Orthopaedics and Biotechnology, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Mathias Vidgren
- Division of Orthopaedics and Biotechnology, CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - Ola Rolfson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy University of Gothenburg, Sweden
| | - Harald Brismar
- Division of Orthopaedics and Biotechnology, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
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Zheng C, Yu G, Su Q, Wu L, Tang J, Lin X, Chen Y, Guo Z, Zheng F, Zheng H, Lin L, Tang Y, Wu S, Li H. The deficiency of N6-methyladenosine demethylase ALKBH5 enhances the neurodegenerative damage induced by cobalt. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 881:163429. [PMID: 37072102 DOI: 10.1016/j.scitotenv.2023.163429] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 06/01/2023]
Abstract
Cobalt exposure, even at low concentrations, induces neurodegenerative damage, such as Alzheimer's disease (AD). The specific underlying mechanisms remain unclear. Our previous study demonstrated that m6A methylation alteration is involved in cobalt-induced neurodegenerative damage, such as in AD. However, the role of m6A RNA methylation and its underlying mechanisms are poorly understood. In this study, both epidemiological and laboratory studies showed that cobalt exposure could downregulate the expression of the m6A demethylase ALKBH5, suggesting a key role for ALKBH5. Moreover, Methylated RNA immunoprecipitation and sequencing (MeRIP-seq) analysis revealed that ALKBH5 deficiency is associated with neurodegenerative diseases. KEGG pathway and Gene ontology analyses further revealed that the differentially m6A-modified genes resulting from ALKBH5 downregulation and cobalt exposure were aggregated in the pathways of proliferation, apoptosis, and autophagy. Subsequently, ALKBH5 deficiency was shown to exacerbate cell viability decline, motivate cell apoptosis and attenuate cell autophagy induced by cobalt with experimental techniques of gene overexpression/inhibition. In addition, morphological changes in neurons and the expression of AD-related proteins, such as APP, P-Tau, and Tau, in the cerebral hippocampus of wild-type and ALKBH5 knockout mice after chronic cobalt exposure were also investigated. Both in vitro and in vivo results showed that lower expression of ALKBH5 aggravated cobalt-induced neurodegenerative damage. These results suggest that ALKBH5, as an epigenetic regulator, could be a potential target for alleviating cobalt-induced neurodegenerative damage. In addition, we propose a novel strategy for the prevention and treatment of environmental toxicant-related neurodegeneration from an epigenetic perspective.
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Affiliation(s)
- Chunyan Zheng
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Guangxia Yu
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Key Lab of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Qianqian Su
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Lingyan Wu
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Jianping Tang
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Xinpei Lin
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Yao Chen
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Zhenkun Guo
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Fuli Zheng
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Key Lab of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Hong Zheng
- Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou 350007, China
| | - Liqiong Lin
- Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou 350007, China
| | - Ying Tang
- Fujian Center for Prevention and Control Occupational Diseases and Chemical Poisoning, Fuzhou 350125, China
| | - Siying Wu
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Key Lab of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou 350122, China.
| | - Huangyuan Li
- Fujian Key Lab of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Key Lab of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou 350122, China.
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Migliorini F, Pilone M, Bell A, Merfort R, Giorgino R, Maffulli N. Serum cobalt and chromium concentration following total hip arthroplasty: a Bayesian network meta-analysis. Sci Rep 2023; 13:6918. [PMID: 37106086 PMCID: PMC10140036 DOI: 10.1038/s41598-023-34177-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/25/2023] [Indexed: 04/29/2023] Open
Abstract
The present systematic review investigated the concentration of chromium (Cr) and cobalt (Co) in serum in patients who have undergone total hip arthroplasty (THA). The first outcome of interest was to investigate the mean concentration in serum of Cr and Co using different material combinations and to verify whether their concentrations change significantly using different patterns of head and liner in THA. The second outcome of interest was to investigate whether the time elapsed from the index surgery to the follow-up, BMI, sex, and side exert an influence on the mean concentration of Cr and Co in serum in patients who have undergone THA. The following material combinations were investigated (head-liner): Ceramic-Co Cr (CoCr), CoCr-CoCr, CoCr-Polyethylene, CoCr high carbide-CoCr high carbide. Data from 2756 procedures were retrieved. The mean length of follow-up was 69.3 ± 47.7 months. The ANOVA test evidenced good comparability in age, length of follow-up, BMI, and sex (P > 0.1). In patients who have undergone THA, the mean concentration in the serum of Co ranged between 0.5 µg/L and 3.5 µg/L, and the mean concentration of Cr from 0.6 to 2.6 µg/L. The difference in the concentration of Co and Cr in serum is strictly related to the implant configuration, with the coupling CoCr-CoCr showing the highest and CoCr-Polyethylene showing the lowest concentration. Patient characteristics, BMI, sex, side and the time elapsed from the index surgery to the last follow-up did not exert a significant influence on the concentration of Co and Cr in serum in patients who have undergone total hip arthroplasty (THA).
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany.
| | - Marco Pilone
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy
- Residency Program in Orthopedics and Traumatology, University of Milan, Milan, Italy
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
| | - Ricarda Merfort
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Riccardo Giorgino
- Residency Program in Orthopedics and Traumatology, University of Milan, Milan, Italy
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, ST4 7QB, Stoke On Trent, England
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, E1 4DG, London, England
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Dislocation of a McMinn-Like Prosthesis with Distinctive Metallosis and Fracture of the Os Ilium. Case Rep Orthop 2021; 2021:6151679. [PMID: 34804622 PMCID: PMC8598352 DOI: 10.1155/2021/6151679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/02/2021] [Indexed: 11/18/2022] Open
Abstract
Osteoarthritis of the hip joint (coxarthrosis) is the most common hip disease in adults. Since the 1960s, total hip arthroplasty (THA) has made great progress and is nowadays one of the most frequently used procedures in orthopedic surgery. Different bearing concepts exist in various implant designs. A metal-on-metal bearing can create metal debris and lead to metallosis. We present a unique case of a 78-year old woman, who received hip resurfacing with a McMinn-like prosthesis 15 years ago. Over the cause of time, metallosis developed and created a bone cyst in the Os ilium, and osteolysis led to a dislocation of the femoral implant. A minor stumble fall led to a fracture of the Os ilium. We present our treatment method with implantation of a cemented THA and refill of the bone cyst with bone from allogene femoral heads. The surgery led to a reconstruction of the physiological center of rotation in the hip. Consequently, to the inpatient stay, the patient took part in a follow-up treatment with intensive physiotherapy. Taken together, the results after total hip arthroplasty are more superior to other hip surface replacements in terms of longevity and patient satisfaction. Especially, metal-on-metal bearing couples carry a great risk of metallosis, which goes a long with pseudotumors, osteolysis, and the elevated metal ions in the blood. Since this case is unique in the literature, no guidelines are noted for surgical treatment. In our opinion, a periprosthetic fracture of this type should be performed in a hospital using extensive endoprosthetic expertise.
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