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Pautasso A, Zorzolo I, Bellato E, Pellegrino P, Ferrario A, Pira E, Castoldi F. Allergic reaction and metal hypersensitivity after shoulder joint replacement. Musculoskelet Surg 2023; 107:55-68. [PMID: 34719773 PMCID: PMC10020248 DOI: 10.1007/s12306-021-00729-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 09/17/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE Metal ion release may cause local and systemic effects and induce hypersensitivity reactions. The aim of our study is first to determine if implant-related hypersensitivity correlates to patient symptoms or not; second, to assess the rate of hypersensitivity and allergies in shoulder arthroplasty. METHODS Forty patients with shoulder replacements performed between 2015 and 2017 were studied with minimum 2-year follow-up; no patient had prior metal implants. Each patient underwent radiographic and clinical evaluation using the Constant-Murley Score (CMS), 22 metal and cement haptens patch testing, serum and urine tests to evaluate 12 metals concentration, and a personal occupational medicine interview. RESULTS At follow-up (average 45 ± 10.7 months), the mean CMS was 76 ± 15.9; no clinical complications or radiographic signs of loosening were detected; two nickel sulfate (5%), 1 benzoyl peroxide (2.5%) and 1 potassium dichromate (2.5%) positive findings were found, but all these patients were asymptomatic. There was an increase in serum aluminum, urinary aluminum and urinary chromium levels of 1.74, 3.40 and 1.83 times the baseline, respectively. No significant difference in metal ion concentrations were found when patients were stratified according to gender, date of surgery, type of surgery, and type of implant. CONCLUSIONS Shoulder arthroplasty is a source of metal ion release and might act as a sensitizing exposure. However, patch test positivity does not seem to correlate to hypersensitivity cutaneous manifestations or poor clinical results. Laboratory data showed small constant ion release over time, regardless of gender, type of shoulder replacement and implant used. LEVELS OF EVIDENCE Level II.
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Affiliation(s)
- A. Pautasso
- University of Turin, Via Gianfranco Zuretti 29, 10126 Turin, Italy
| | - I. Zorzolo
- University of Turin, Via Gianfranco Zuretti 29, 10126 Turin, Italy
| | - E. Bellato
- Orthopaedic and Traumatology Department, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043 Orbassano, Italy
| | - P. Pellegrino
- Oncologic Orthopaedic Department, Orthopaedic and Trauma Center – Città della Salute e della Scienza, University of Turin, Via Gianfranco Zuretti 29, 10126 Turin, Italy
| | - A. Ferrario
- Occupational Medicine Division, Department of Public Health and Pediatric Sciences, Orthopaedic and Trauma Center – Città della Salute e della Scienza, University of Turin, Via Gianfranco Zuretti 29, 10126 Turin, Italy
| | - E. Pira
- University of Turin, Via Gianfranco Zuretti 29, 10126 Turin, Italy
- Occupational Medicine Division, Department of Public Health and Pediatric Sciences, Orthopaedic and Trauma Center – Città della Salute e della Scienza, University of Turin, Via Gianfranco Zuretti 29, 10126 Turin, Italy
| | - F. Castoldi
- University of Turin, Via Gianfranco Zuretti 29, 10126 Turin, Italy
- Orthopaedic and Traumatology Department, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043 Orbassano, Italy
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Langton DJ, Bhalekar RM, Joyce TJ, Rushton SP, Wainwright BJ, Nargol ME, Shyam N, Lie BA, Pabbruwe MB, Stewart AJ, Waller S, Natu S, Ren R, Hornick R, Darlay R, Su EP, Nargol AVF. The influence of HLA genotype on the development of metal hypersensitivity following joint replacement. COMMUNICATIONS MEDICINE 2022; 2:73. [PMID: 35761834 PMCID: PMC9232575 DOI: 10.1038/s43856-022-00137-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 06/07/2022] [Indexed: 12/27/2022] Open
Abstract
Background Over five million joint replacements are performed across the world each year. Cobalt chrome (CoCr) components are used in most of these procedures. Some patients develop delayed-type hypersensitivity (DTH) responses to CoCr implants, resulting in tissue damage and revision surgery. DTH is unpredictable and genetic links have yet to be definitively established. Methods At a single site, we carried out an initial investigation to identify HLA alleles associated with development of DTH following metal-on-metal hip arthroplasty. We then recruited patients from other centres to train and validate an algorithm incorporating patient age, gender, HLA genotype, and blood metal concentrations to predict the development of DTH. Accuracy of the modelling was assessed using performance metrics including time-dependent receiver operator curves. Results Using next-generation sequencing, here we determine the HLA genotypes of 606 patients. 176 of these patients had experienced failure of their prostheses; the remaining 430 remain asymptomatic at a mean follow up of twelve years. We demonstrate that the development of DTH is associated with patient age, gender, the magnitude of metal exposure, and the presence of certain HLA class II alleles. We show that the predictive algorithm developed from this investigation performs to an accuracy suitable for clinical use, with weighted mean survival probability errors of 1.8% and 3.1% for pre-operative and post-operative models respectively. Conclusions The development of DTH following joint replacement appears to be determined by the interaction between implant wear and a patient's genotype. The algorithm described in this paper may improve implant selection and help direct patient surveillance following surgery. Further consideration should be given towards understanding patient-specific responses to different biomaterials.
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Affiliation(s)
- David J. Langton
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, England
| | - Rohan M. Bhalekar
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, England
| | | | | | | | - Matthew E. Nargol
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, England
| | - Nish Shyam
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, England
| | - Benedicte A. Lie
- Department of Medical Genetics, University of Oslo and Oslo University Hospital, Oslo, Norway
| | | | - Alan J. Stewart
- School of Medicine, University of St Andrews, St Andrews, Scotland
| | - Susan Waller
- University Hospital of North Tees, Stockton, England
| | - Shonali Natu
- University Hospital of North Tees, Stockton, England
| | - Renee Ren
- Hospital for Special Surgery, New York, USA
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Kenny F, Gibbons JP, Keogh P, O'Byrne J. Revision of total knee replacement (TKR) secondary to raised cobalt levels: should this be considered in the painful TKR patient? BMJ Case Rep 2021; 14:14/7/e240674. [PMID: 34266815 DOI: 10.1136/bcr-2020-240674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 63-year-old woman was referred to the specialised knee revision clinic with ongoing knee pain after total knee replacement. She incidentally had cobalt and chromium levels measured. These were seen to be elevated. Comprehensive assessment and investigation did not identify any other source of cobalt or chromium. Aseptic loosening of the knee was diagnosed, and the knee was revised. At the time of surgery, the tissue was seen to be darkened consistent with metallosis. Multiple samples excluded infection on extended cultures. Aspirated fluid showed that periprosthetic fluid had elevated cobalt levels. The knee was successfully revised with good symptomatic outcome and significantly, over the course of several months post-revision, the cobalt and chromium levels returned to normal.
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Affiliation(s)
- Fred Kenny
- School of Medicine, University of Limerick, Castletroy, Limerick, Ireland
| | - John P Gibbons
- Orthopaedic Department, Cappagh National Orthopaedic Hospital, Dublin, Ireland
| | - Peter Keogh
- Orthopaedic Department, Cappagh National Orthopaedic Hospital, Dublin, Ireland
| | - John O'Byrne
- Orthopaedic Department, Cappagh National Orthopaedic Hospital, Dublin, Ireland
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Roy ME, Whiteside LA, Ly KK, Gauvain MJ. Cobalt-chromium femoral components developed scratches and released metal debris in simulated wear whereas ceramic femoral components did not. Bone Joint J 2021; 103-B:94-101. [PMID: 34053284 DOI: 10.1302/0301-620x.103b6.bjj-2020-2429.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS The aims of this study were to evaluate wear on the surface of cobalt-chromium (CoCr) femoral components used in total knee arthroplasty (TKA) and compare the wear of these components with that of ceramic femoral components. METHODS Optical profilometry was used to evaluate surface roughness and to examine the features created by the wear process in a knee wear simulator. We developed a method of measuring surface changes on five CoCr femoral components and quantifying the loss of material from the articular surface during the wear process. We also examined the articular surface of three ceramic femoral components from a previous test for evidence of surface damage, and compared it with that of CoCr components. RESULTS We found that the surface roughness of CoCr components rapidly increased during the first 1,000 wear cycles, then reached a steady state, but material loss from the surface continued at a rate of 1,778,000 μm3 per million cycles as carbides were removed from its matrix. These carbides formed third-body wear particles, leading to the formation of new scratches even as older scratches were worn away. In contrast, no scratching, loss of material, or other surface damage, when evaluated with one nanometer resolution, was found on the surface of the ceramic components after a 15 M wear cycle test. CONCLUSION This study showed wear and loss of CoCr material from scratching and microabrasive wear in TKA. The material loss from the surface continued in a linear relationship with increasing cycles. We also found the absence of scratching and roughening of ceramic femoral components in simulated wear, suggesting an advantage in wear rate and avoiding metal sensitivity. This may have implications in the management of persistent pain after TKA. Cite this article: Bone Joint J 2021;103-B(6 Supple A):94-101.
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Affiliation(s)
- Marie E Roy
- Missouri Bone & Joint Research Foundation, St Louis, Missouri, USA
| | - Leo A Whiteside
- Missouri Bone & Joint Research Foundation, St Louis, Missouri, USA
| | - Kevin K Ly
- Missouri Bone & Joint Research Foundation, St Louis, Missouri, USA
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Is There Material Loss at the Conical Junctions of Modular Components for Total Knee Arthroplasty? J Arthroplasty 2019; 34:2479-2486. [PMID: 31227303 DOI: 10.1016/j.arth.2019.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Clinical concern exists regarding fretting corrosion and material loss from taper junctions in orthopedic devices, with previous research focusing on the modular components from total hip arthroplasty. Comparatively little has been published regarding the fretting corrosion and material loss in modular knee devices. The purpose of this study is to evaluate fretting corrosion damage and quantify material loss for conical total knee arthroplasty taper interfaces. METHODS Stem tapers of 166 retrieved modular knee devices were evaluated for fretting corrosion using a semiquantitative scoring method. High precision profilometry was then used to determine volumetric material loss and maximum wear depth for a subset of 37 components (implanted for 0.25-18.76 years). Scanning electron microscopy and energy-dispersive X-ray spectroscopy were used to characterize the observed damage. RESULTS Mild to severe fretting corrosion was observed on the majority of tapers, with 23% receiving a maximum visually determined damage score of 4. The median rate of volumetric material loss was 0.11 mm3/y (range 0.00-0.76) for femoral components (both cone and bore taper surfaces combined) and 0.01 mm3 (range 0.00-8.10) for tibial components. Greater rates of material loss were associated with mixed metal pairings. There was a strong correlation between visual fretting corrosion score and calculated material loss (ρ = 0.68, P < .001). Scanning electron microscopy revealed varying degrees of scratching, wear, fretting corrosion, and instances of cracking with morphology not consistent with fretting corrosion, wear, or fatigue. CONCLUSION Although visual evidence of fretting corrosion damage was prevalent and correlated with taper material loss, the measured volumetric material loss was low compared with prior reports from total hip arthroplasty.
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Reiner T, Bader N, Panzram B, Bülhoff M, Omlor G, Kretzer JP, Raiss P, Zeifang F. In vivo blood metal ion levels in patients after total shoulder arthroplasty. J Shoulder Elbow Surg 2019; 28:539-546. [PMID: 30518478 DOI: 10.1016/j.jse.2018.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/17/2018] [Accepted: 08/19/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Products from metal wear have been identified as a potential cause of adverse local tissue reactions and implant failure in total hip arthroplasty. However, the role of metal ion exposure in patients after total shoulder replacement is unclear. The objective of the present study was to determine in vivo blood metal ion levels of cobalt, chromium, and titanium in patients after anatomic total shoulder arthroplasty (TSA) or reverse TSA. METHODS A consecutive series of patients after anatomic TSA or reverse TSA was evaluated retrospectively. After exclusion of patients with additional metal implants, 40 patients with unilateral anatomic TSA (n = 20) or reverse TSA (n = 20) were available for whole-blood metal ion analysis at a mean follow-up of 28 ± 9.6 months. Twenty-three healthy individuals without metal implants served as a control group. RESULTS Mean cobalt ion concentrations were 0.18 µg/L (range, 0.1-0.66 µg/L), 0.15 µg/L (range, 0.03-0.48 µg/L), and 0.11 µg/L (range, 0.03-0.19 µg/L), mean chromium ion levels were 0.48 µg/L (range, 0.17-2.41 µg/L), 0.31 µg/L (range, 0.09-1.26 µg/L), and 0.14 µg/L (range, 0.04-0.99 µg/L), and mean titanium ion concentrations were 1.31 µg/L (range, 0.75-4.52 µg/L), 0.84 µg/L (range, 0.1-1.64 µg/L), and 0.62 µg/L (range, 0.32-2.14 µg/L) in the reverse TSA group, the anatomic TSA group, and the control group, respectively. CONCLUSIONS TSA resulted in elevated metal ion levels compared with healthy controls, although overall metal ion concentrations measured in this study were relatively low. The role of local metal ion exposure in patients with total shoulder replacements should be further investigated.
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Affiliation(s)
- Tobias Reiner
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.
| | - Nina Bader
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Panzram
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Bülhoff
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Georg Omlor
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan P Kretzer
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Patric Raiss
- OCM (Orthopädische Chirurgie München) Clinic for Orthopedic Surgery, Munich, Germany
| | - Felix Zeifang
- Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
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Kutzner I, Hallan G, Høl PJ, Furnes O, Gøthesen Ø, Figved W, Ellison P. Early aseptic loosening of a mobile-bearing total knee replacement. Acta Orthop 2018; 89:77-83. [PMID: 29105532 PMCID: PMC5810837 DOI: 10.1080/17453674.2017.1398012] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/29/2017] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - Registry-based studies have reported an increased risk of aseptic tibial loosening for the cemented Low Contact Stress (LCS) total knee replacement compared with other cemented designs; however, the reasons for this have not been established. We made a retrieval analysis with the aim of identifying the failure mechanism. Patients and methods - We collected implants, cement, tissue, blood, and radiographs from 32 failed LCS Complete cases. Damage to the tibial baseplate and insert was assessed. Exposure to wear products was quantified in 11 cases through analysis of periprosthetic tissue and blood. Implant alignment and bone cement thickness was compared with a control group of 43 non-revised cases. Results - Loosening of the tibial baseplate was the reason for revision in 25 retrievals, occurring at the implant-cement interface in 16 cases. Polishing was observed on the lower surface of the baseplate and correlated to the level of cobalt, chromium, and zirconium in the blood. No evidence of abnormally high polyethylene wear was present. For each 1 mm increase in cement thickness the odds of failure due to aseptic loosening decreased by 61%. Greater varus alignment was associated with a shorter time to failure. The roughness, Ra, of a new LCS baseplate's lower surface was 3.7 (SD 0.7) µm. Interpretation - Debonding of the tibial component at the implant-cement interface was the predominant cause of tibial aseptic loosening. A thin cement layer may partly explain the poor performance. Furthermore, the comparatively low tibial surface roughness and the lack of a keeled stem may have played a role in the failures observed.
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Affiliation(s)
- Ines Kutzner
- Department of Clinical Medicine, University of Bergen, Norway
- Julius Wolff Institute, Charité—Universitätsmedizin Berlin, Germany
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Paul Johan Høl
- Department of Clinical Medicine, University of Bergen, Norway
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ove Furnes
- Department of Clinical Medicine, University of Bergen, Norway
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Øystein Gøthesen
- Department of Clinical Medicine, University of Bergen, Norway
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
- Haugesund Hospital, Haugesund, Norway
| | - Wender Figved
- Orthopedic Department, Baerum Hospital, Vestre Viken Hospital Trust, Norway
| | - Peter Ellison
- Department of Clinical Medicine, University of Bergen, Norway
- Department of Mechanical Engineering, Imperial College London, UK
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Koller D, Bramhall P, Devoy J, Goenaga-Infante H, Harrington CF, Leese E, Morton J, Nuñez S, Rogers J, Sampson B, Powell JJ. Analysis of soluble or titanium dioxide derived titanium levels in human whole blood: consensus from an inter-laboratory comparison. Analyst 2018; 143:5520-5529. [DOI: 10.1039/c8an00824h] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Exposure to titanium (Ti),viathe ingestion of pigment grade Ti dioxide (TiO2), is commonplace for westernised populations.
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Affiliation(s)
- D. Koller
- Biomineral Research Group
- Department of Veterinary Medicine
- University of Cambridge
- Cambridge
- UK
| | - P. Bramhall
- University Hospital of Wales TRACE ELEMENT LABORATORY
- Department of Medical Biochemistry and Immunology
- Cardiff
- UK
| | - J. Devoy
- INRS
- Unité de Génération d'atmosphères et de Chimie Analytique Toxicologique
- 54519 Vandoeuvre-lès-Nancy
- France
| | | | | | - E. Leese
- Health and Safety Executive
- Biological Monitoring
- Buxton
- UK
| | - J. Morton
- Health and Safety Executive
- Biological Monitoring
- Buxton
- UK
| | - S. Nuñez
- LGC Limited
- Inorganic Analysis
- Teddington
- UK
| | - J. Rogers
- University Hospital of Wales TRACE ELEMENT LABORATORY
- Department of Medical Biochemistry and Immunology
- Cardiff
- UK
| | - B. Sampson
- Charing Cross Hospital
- SAS Trace Element Laboratory
- London
- UK
| | - J. J. Powell
- Biomineral Research Group
- Department of Veterinary Medicine
- University of Cambridge
- Cambridge
- UK
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Lons A, Putman S, Pasquier G, Migaud H, Drumez E, Girard J. Metallic ion release after knee prosthesis implantation: a prospective study. INTERNATIONAL ORTHOPAEDICS 2017; 41:2503-2508. [PMID: 28616704 DOI: 10.1007/s00264-017-3528-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 05/25/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Metal-on-metal (MoM) hip replacement bearings produce metallic ions that can cause health complications. Metallic release also occurs with other materials, but data on metallic ion levels after knee arthroplasty are sparse. We postulate that knee replacement generates elevating metallic ions (chromium (Cr), cobalt (Co) and titanium (Ti)) during the first year after implantation. PATIENTS AND METHODS This ongoing prospective study included all patients who underwent the same type of knee arthroplasty between May and December 2013. Cr, Co and Ti levels were measured in whole blood at pre-operation and one-year follow-up (6 and 12 months). Clinical and radiographic data (range of motion, Oxford, International Knee Society (IKS) and satisfaction scores) were recorded. RESULTS In 90 patients, preoperative Cr, Co and Ti metallic ion levels were respectively 0.45 μg/l, 0.22 μg/l, 2.94 μg/l and increased to 1.27 μg/l, 1.41 μg/l, 4.08 μg/l (p < 0.0001) at last one-year follow-up. Mean Oxford and IKS scores rose, respectively, from 45.9 (30-58) and 24.9 (12-52) to 88.3 (0-168) and 160.8 (93-200) (p < 0.001). CONCLUSION After the implantation of knee arthroplasty, we found significant blood elevation of Cr, Co and Ti levels one year after implantation exceeding the normal values. This metallic ion release could lead to numerous effects: allergy, hypersensitivity, etc.
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Affiliation(s)
- Adrien Lons
- Université de Lille Nord de France, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037, Lille, Cedex, France
| | - Sophie Putman
- Université de Lille Nord de France, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037, Lille, Cedex, France
| | - Gilles Pasquier
- Université de Lille Nord de France, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037, Lille, Cedex, France
| | - Henri Migaud
- Université de Lille Nord de France, F-59000, Lille, France
- Service d'Orthopédie, Hôpital Salengro, Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037, Lille, Cedex, France
| | - Elodie Drumez
- Unité de Biostatistiques, Université Lille, Centre Hospitalier Universitaire Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000, Lille, France
| | - Julien Girard
- Université de Lille Nord de France, F-59000, Lille, France.
- Service d'Orthopédie, Hôpital Salengro, Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037, Lille, Cedex, France.
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Middleton S, Toms A. Allergy in total knee arthroplasty: a review of the facts. Bone Joint J 2016; 98-B:437-41. [PMID: 27037424 DOI: 10.1302/0301-620x.98b4.36767] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 10/21/2015] [Indexed: 12/18/2022]
Abstract
We explored the literature surrounding whether allergy and hypersensitivity has a clinical basis for implant selection in total knee arthroplasty (TKA). In error, the terms hypersensitivity and allergy are often used synonymously. Although a relationship is present, we could not find any evidence of implant failure due to allergy. There is however increasing basic science that suggests a link between loosening and metal ion production. This is not an allergic response but is a potential problem. With a lack of evidence logically there can be no justification to use 'hypoallergenic' implants in patients who have pre-existing skin sensitivity to the metals used in TKA.
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Affiliation(s)
- S Middleton
- Royal Devon and Exeter Hospitals Foundation Trust, Barrack Rd, Exeter, EX2 5DW, UK
| | - A Toms
- Royal Devon and Exeter Hospitals Foundation Trust, Barrack Rd, Exeter, EX2 5DW, UK
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12
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Fage SW, Muris J, Jakobsen SS, Thyssen JP. Titanium: a review on exposure, release, penetration, allergy, epidemiology, and clinical reactivity. Contact Dermatitis 2016; 74:323-45. [PMID: 27027398 DOI: 10.1111/cod.12565] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 02/07/2016] [Accepted: 02/08/2016] [Indexed: 11/29/2022]
Abstract
Exposure to titanium (Ti) from implants and from personal care products as nanoparticles (NPs) is common. This article reviews exposure sources, ion release, skin penetration, allergenic effects, and diagnostic possibilities. We conclude that human exposure to Ti mainly derives from dental and medical implants, personal care products, and foods. Despite being considered to be highly biocompatible relative to other metals, Ti is released in the presence of biological fluids and tissue, especially under certain circumstances, which seem to be more likely with regard to dental implants. Although most of the studies reviewed have important limitations, Ti seems not to penetrate a competent skin barrier, either as pure Ti, alloy, or as Ti oxide NPs. However, there are some indications of Ti penetration through the oral mucosa. We conclude that patch testing with the available Ti preparations for detection of type IV hypersensitivity is currently inadequate for Ti. Although several other methods for contact allergy detection have been suggested, including lymphocyte stimulation tests, none has yet been generally accepted, and the diagnosis of Ti allergy is therefore still based primarily on clinical evaluation. Reports on clinical allergy and adverse events have rarely been published. Whether this is because of unawareness of possible adverse reactions to this specific metal, difficulties in detection methods, or the metal actually being relatively safe to use, is still unresolved.
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Affiliation(s)
- Simon W Fage
- Department of Dermato-Venereology, Aarhus University Hospital, 8000 Aarhus, Denmark
| | - Joris Muris
- Department of Dental Materials Science, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Gustav Mahlerlaan 3004, 1081 LA, Amsterdam, The Netherlands
| | - Stig S Jakobsen
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8000 Aarhus, Denmark
| | - Jacob P Thyssen
- National Allergy Research Centre, Department of Dermato-Allergology, Copenhagen University Hospital Herlev-Gentofte, 2900 Hellerup, Denmark
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Golasik M, Herman M, Piekoszewski W. Toxicological aspects of soluble titanium – a review of in vitro and in vivo studies. Metallomics 2016; 8:1227-1242. [DOI: 10.1039/c6mt00110f] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Jelinek M, Zemek J, Vandrovcová M, Bačáková L, Kocourek T, Remsa J, Písařík P. Bonding and bio-properties of hybrid laser/magnetron Cr-enriched DLC layers. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2015; 58:1217-24. [PMID: 26478424 DOI: 10.1016/j.msec.2015.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/19/2015] [Accepted: 09/03/2015] [Indexed: 10/23/2022]
Abstract
Chromium-enriched diamond-like carbon (DLC) layers were prepared by a hybrid technology using a combination of pulsed laser deposition (PLD) and magnetron sputtering. XRD revealed no chromium peaks, indicating that the layers are mostly amorphous. Carbon (sp(2) and sp(3) bonds) and chromium bonds were determined by XPS from C 1s, O 1s, and Cr 2p photoelectron peaks. Depending on the deposition conditions, the concentration of Cr in DLC layers moved from zero to 10 at.% for as-received sample surfaces, and to about 31 at.% after mild sputter-cleaning by argon ion cluster beam. It should be noted that the most stable Cr(3+) bonding state is in Cr2O3 and Cr(OH)3, and that there is the toxic Cr(6+) state in CrO3. The surface content of hexavalent chromium in the Cr 2p3/2 spectra is rather low, but discernible. The population density of Saos-2 cells was the highest in samples containing higher concentrations of chromium 7.7 and 10 at.%. This means that higher concentrations of chromium supported the cell adhesion and proliferation. In addition, as revealed by a LIVE/DEAD viability/cytotoxicity kit, the cells on all Cr-containing samples maintained high viability (96 to 99%) on days 1 and 3 after seeding. However, this seemingly positive cell behavior could be associated with the risk of dedifferentiation and oncogenic transformation of cells.
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Affiliation(s)
- Miroslav Jelinek
- Institute of Physics, Academy of Sciences of the Czech Republic, v.v.i, Na Slovance 2, 18221 Prague, Czech Republic; Czech Technical University in Prague, Faculty of Biomedical Engineering, nam. Sitna 3105, 27201 Kladno, Czech Republic.
| | - Josef Zemek
- Institute of Physics, Academy of Sciences of the Czech Republic, v.v.i, Na Slovance 2, 18221 Prague, Czech Republic
| | - Marta Vandrovcová
- Institute of Physiology of the Czech Academy of Sciences of the Czech Republic, v.v.i., Videnska 1083, 14220 Prague 4, Czech Republic
| | - Lucie Bačáková
- Institute of Physiology of the Czech Academy of Sciences of the Czech Republic, v.v.i., Videnska 1083, 14220 Prague 4, Czech Republic
| | - Tomáš Kocourek
- Institute of Physics, Academy of Sciences of the Czech Republic, v.v.i, Na Slovance 2, 18221 Prague, Czech Republic; Czech Technical University in Prague, Faculty of Biomedical Engineering, nam. Sitna 3105, 27201 Kladno, Czech Republic
| | - Jan Remsa
- Institute of Physics, Academy of Sciences of the Czech Republic, v.v.i, Na Slovance 2, 18221 Prague, Czech Republic; Czech Technical University in Prague, Faculty of Biomedical Engineering, nam. Sitna 3105, 27201 Kladno, Czech Republic
| | - Petr Písařík
- Institute of Physics, Academy of Sciences of the Czech Republic, v.v.i, Na Slovance 2, 18221 Prague, Czech Republic; Czech Technical University in Prague, Faculty of Biomedical Engineering, nam. Sitna 3105, 27201 Kladno, Czech Republic
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Kretzer JP, Reinders J, Sonntag R, Hagmann S, Streit M, Jeager S, Moradi B. Wear in total knee arthroplasty--just a question of polyethylene?: Metal ion release in total knee arthroplasty. INTERNATIONAL ORTHOPAEDICS 2013; 38:335-40. [PMID: 24218115 DOI: 10.1007/s00264-013-2162-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 10/20/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE Biological reactions against wear particles are a common cause for revision in total knee arthroplasty. To date, wear has mainly been attributed to polyethylene. However, the implants have large metallic surfaces that also could potentially lead to metal wear products (metal ions and debris). The aim of this study was to determine the local release of cobalt, chromium, molybdenum and titanium in total knee arthroplasty during a standard knee wear test. METHODS Four moderately conforming fixed-bearing implants were subjected to physiological loadings and motions for 5×10(6) walking cycles in a knee wear simulator. Polyethylene wear was determined gravimetrically and the release of metallic wear products was measured using high resolution-inductively coupled plasma-mass spectrometry. RESULTS A polyethylene wear rate of 7.28 ± 0.27 mg/10(6) cycles was determined and the cumulative mass of released metals measured 1.63 ± 0.28 mg for cobalt, 0.47 ± 0.06 mg for chromium, 0.42 ± 0.06 mg for molybdenum and 1.28 ± 0.14 mg for titanium. CONCLUSION For other metallic implants such as metal-on-metal total hip arthroplasty, the metal wear products can interact with the immune system, potentially leading to immunotoxic effects. In this study about 12 % by weight of the wear products were metallic, and these particles and ions may become clinically relevant for patients sensitive to these materials in particular. Non-metallic materials (e.g. ceramics or suitable coatings) may be considered for an alternative treatment for those patients.
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Affiliation(s)
- Jan Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics & Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany,
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Abstract
STUDY DESIGN A prospective cohort study. OBJECTIVE To determine serum titanium, niobium, and aluminum levels in pediatric patients within the first postoperative year after instrumented spinal arthrodesis. SUMMARY OF BACKGROUND DATA Instrumented spinal arthrodesis is a common procedure to correct scoliosis and kyphosis. Titanium-based instrumentation is increasingly favored due to enhanced biomechanical properties, but concerns have arisen regarding metal debris release and the potential for local and systemic complications. METHODS The pattern of systemic metal release over time was evaluated by measuring serum titanium, niobium, and aluminum levels preoperatively and 1 week, 1 month, 6 months, and 12 months after instrumented spinal arthrodesis using a titanium alloy. Serum metal levels were measured using high-resolution inductively coupled plasma mass spectrometry. RESULTS Thirty-two patients were included in the study group. Mean age at surgery was 14.7 years. Preoperative and postoperative concentrations of serum titanium and niobium were significantly different (P = 0.0001). Median postoperative serum concentrations of titanium and niobium were elevated 2.4- and 5.9-fold above the normal range respectively with 95% and 99% of samples elevated postoperatively. A significant and rapid rise in serum titanium and niobium levels was observed within the first postoperative week, after which elevated serum levels persisted up to 12 months. CONCLUSION We report abnormally elevated serum titanium and niobium levels in patients with titanium-based spinal instrumentation up to 12 months. The long-term systemic consequences of debris generated by wear and corrosion of spinal instrumentation is unclear but concerning, particularly as these implants inserted into the pediatric population may remain in situ for beyond 6 decades.
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Harvie P, Torres-Grau J, Beaver RJ. Common peroneal nerve palsy associated with pseudotumour after total knee arthroplasty. Knee 2012; 19:148-50. [PMID: 21497506 DOI: 10.1016/j.knee.2011.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 01/16/2011] [Accepted: 02/04/2011] [Indexed: 02/02/2023]
Abstract
Pseudotumours about the hip as a result of metal-on-metal wear debris are now widely reported. Nerve palsies associated with such lesions are less commonly described. To our knowledge no previous reports exist which describe pseudotumours about a total knee arthroplasty. The case of a metal-on-metal debris-induced pseudotumour about a total knee arthroplasty with an associated common peroneal nerve palsy is presented. The use of serum ion levels is discussed, specifically for the early detection and diagnosis of full-thickness polyethylene liner wear and subsequent revision options.
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Affiliation(s)
- Paul Harvie
- The Department Of Elective Orthopaedics, Royal Perth Hospital, Shenton Park, Western Australia 6008.
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Cenni E, Scioscia L, Baldini N. Orthopaedic research in italy: state of the art. Int J Immunopathol Pharmacol 2011; 24:157-78. [PMID: 21669157 DOI: 10.1177/03946320110241s230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The most significant results in experimental and clinical orthopaedic research in Italy within the last three years have been primarily in major congenital diseases, bone tumors, regenerative medicine, joint replacements, spine, tendons and ligaments. The data presented in the following discussion is comparable with leading international results, highlighting Italian orthopaedic research excellemce as well as its shortcomings.
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Affiliation(s)
- E Cenni
- Istituto Ortopedico Rizzoli, Bologna, Italy
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Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and systemic hypersensitivity reactions to metallic implants. Dermatitis 2011. [PMID: 21504692 DOI: 10.2310/6620.2011.10055] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cutaneous reactions to metal implants, orthopedic or otherwise, are well documented in the literature. The first case of a dermatitis reaction over a stainless steel fracture plate was described in 1966. Most skin reactions are eczematous and allergic in nature, although urticarial, bullous, and vasculitic eruptions may occur. Also, more complex immune reactions may develop around the implants, resulting in pain, inflammation, and loosening. Nickel, cobalt, and chromium are the three most common metals that elicit both cutaneous and extracutaneous allergic reactions from chronic internal exposure. However, other metal ions as well as bone cement components can cause such hypersensitivity reactions. To complicate things, patients may also develop delayed-type hypersensitivity reactions to metals (ie, in-stent restenosis, prosthesis loosening, inflammation, pain, or allergic contact dermatitis) following the insertion of intravascular stents, dental implants, cardiac pacemakers, or implanted gynecologic devices. Despite repeated attempts by researchers and clinicians to further understand this difficult area of medicine, the association between metal sensitivity and cutaneous allergic reactions remains to be fully understood. This review provides an update of the current knowledge in this field and should be valuable to health care providers who manage patients with conditions related to this field.
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