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Herbster M, Müller E, Jahn J, Buchholz A, Tootsi K, Lohmann CH, Halle T, Bertrand J. In vivo corrosion on retrieved hip endoprostheses and in vitro effects of corrosion products on bone mineralization. Bone 2023; 175:116852. [PMID: 37473933 DOI: 10.1016/j.bone.2023.116852] [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: 04/03/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/22/2023]
Abstract
In vivo corrosion of modular endoprostheses remains a great concern, as the release of heavy metal ions can impair the implant's service life and the wellbeing of the patient. The detailed corrosion mechanisms that occur in vivo are so far not completely understood. In this context, the effects of implant released cobalt (Co) and chromium (Cr) ions on osteoblast mineralization and gene expression have not been investigated extensively. This comprehensive study aimed at furthering the understanding of in vivo implant corrosion from the clinical signs via prosthesis retrievals and histology of the synovial membranes down to the molecular processes instigated by corrosion products and its effects on bone mineralization. A detailed in vivo failure analysis was performed investigating 22 retrieved hip endoprostheses from different manufacturers and taper material combinations. The aim was to find a correlation of taper damage and especially corrosion to susceptible biomedical alloys and its effect on periprosthetic tissue as well as the clinical implant performance with regard to revision diagnosis and presence of radiolucent lines (RLL). A second part investigated the effects of Co and Cr ions on the in vitro mineralization process of osteoblasts. Cell cultures were exposed to relevant concentrations of CoCl2 and CrCl3 (0 μM, 100 μM, 200 μM) with and without addition of phosphate. Mineralization behavior was analyzed with Alizarin Red assay and Von Kossa staining of calcium depots, alkaline phosphatase activity of osteoblasts and gene expression was analyzed with real time quantitative PCR. The retrieval study provides evidence of in vivo fretting and crevice corrosion on all metallic tapers combined with either ceramic or metal femoral heads. Within the modular taper junctions, selective dissolution of the α phase occurred in wrought TiAl6V4 alloys, and etching of the fine-grained wrought CoCr28Mo6 alloy implants was observed in formed crevices. In addition, significant amounts of wear particles and corrosion products were detected in retrieved synovial membranes. An increased risk for the occurrence of a RLL in the proximal zones was determined for patients with a corroded mixed metal taper. Whereas Co ions have hardly any effects on mineralization, Cr ions cause a significant concentration dependent decrease in mineralization rate of osteoblasts. However, this effect is alleviated by addition of a phosphate source. Our data reveal that Cr ions depleted dissolved phosphates by forming an insoluble complex (CrPO4), which inhibits the phosphate dependent mineralization process. No significant effect of the heavy metal ions on osteoblast activity by means of alkaline phosphate activity as well as on gene expression is determined. This study broadens the understanding of in vivo corrosion of metallic modular implants and its clinically relevant effects on mineralization. Based on these findings, in vivo corrosion of CoCr28Mo6 endoprostheses should be limited to avoid inhibitory effects of Cr3+ on bone mineralization which can contribute to premature implant failure.
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Affiliation(s)
- Maria Herbster
- Institute of Materials and Joining Technology, Otto-von-Guericke University Magdeburg, Germany.
| | - Eva Müller
- Department of Orthopedic Surgery, Otto-von-Guericke University Magdeburg, Germany
| | - Jannik Jahn
- Department of Orthopedic Surgery, Otto-von-Guericke University Magdeburg, Germany
| | - Adrian Buchholz
- Department of Orthopedic Surgery, Otto-von-Guericke University Magdeburg, Germany
| | - Kaspar Tootsi
- Department of Orthopedic Surgery, Otto-von-Guericke University Magdeburg, Germany; Department of Traumatology and Orthopedics, University of Tartu, Tartu University Hospital, Tartu, Estonia
| | - Christoph H Lohmann
- Department of Orthopedic Surgery, Otto-von-Guericke University Magdeburg, Germany
| | - Thorsten Halle
- Institute of Materials and Joining Technology, Otto-von-Guericke University Magdeburg, Germany
| | - Jessica Bertrand
- Department of Orthopedic Surgery, Otto-von-Guericke University Magdeburg, Germany
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Díaz-Dilernia F, Sanchez-Mele H, Zanotti G, Comba F, Piccaluga F, Buttaro M. Fracture of a triple-polished tapered cemented femoral stem at the Morse taper after metal-on-metal primary total hip arthroplasty. Ann R Coll Surg Engl 2022; 104:e128-e132. [PMID: 34939858 PMCID: PMC9773908 DOI: 10.1308/rcsann.2021.0187] [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: 11/22/2022] Open
Abstract
Total hip arthroplasty, one of the most successful orthopaedic procedures, is influenced by several variables. Corrosion at the modular junction is known as trunnionosis. Despite being reported infrequently, corrosion between the femoral head and the Morse taper can result in severe complications. Fracture of the femoral component in primary metal-on-metal (MoM) total hip arthroplasty at the Morse taper is an extremely rare event and can be associated with several risk factors. We report a case of corrosion at the Morse taper in a hybrid primary MoM total hip arthroplasty, resulting in Morse taper fracture with consequent femoral head entrapment inside the acetabular component. We hypothesise that some risk factors, such as age over 60years, active male patients, body mass index above 30kg/m2, large femoral heads, high-offset stems, 9/10 Morse taper and MoM-bearing surfaces, are associated with this mode of failure.
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Affiliation(s)
- F Díaz-Dilernia
- Institute of Orthopedics ‘Carlos E. Ottolenghi’, Italian Hospital of Buenos Aires, Argentina
| | - H Sanchez-Mele
- Institute of Orthopedics ‘Carlos E. Ottolenghi’, Italian Hospital of Buenos Aires, Argentina
| | - G Zanotti
- Institute of Orthopedics ‘Carlos E. Ottolenghi’, Italian Hospital of Buenos Aires, Argentina
| | - F Comba
- Institute of Orthopedics ‘Carlos E. Ottolenghi’, Italian Hospital of Buenos Aires, Argentina
| | - F Piccaluga
- Institute of Orthopedics ‘Carlos E. Ottolenghi’, Italian Hospital of Buenos Aires, Argentina
| | - M Buttaro
- Institute of Orthopedics ‘Carlos E. Ottolenghi’, Italian Hospital of Buenos Aires, Argentina
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Serum Indicators of Oxidative Damage from Embedded Metal Fragments in a Rat Model. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5394303. [PMID: 35154566 PMCID: PMC8828353 DOI: 10.1155/2022/5394303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/04/2021] [Accepted: 01/04/2022] [Indexed: 11/24/2022]
Abstract
Injuries suffered in armed conflicts often result in embedded metal fragments. Standard surgical guidance recommends leaving embedded fragments in place except under certain circumstances in an attempt to avoid the potential morbidity that extensive surgery often brings. However, technological advances in weapon systems and insurgent use of improvised explosive devices now mean that practically any metal can be found in these types of wounds. Unfortunately, in many cases, the long-term toxicological properties of embedded metals are not known, further complicating treatment decisions. Because of concerns over embedded metal fragment injuries, the U.S. Departments of Defense and Veterans' Affairs developed a list of “metals of concern” for these types of injuries. In this study, we selected eight of these metals including tungsten, nickel, cobalt, iron, copper, aluminum, lead, and depleted uranium to investigate the long-term health effects using a rodent model developed in our Institute to study embedded fragment injuries. In this report, we show that metals surgically implanted into the gastrocnemius muscle of laboratory rats to simulate a shrapnel wound induce a variety of cytokines including IFN-γ, IL-4, IL-5, IL-6, IL-10, and IL-13. TNF-α and KC/GRO were not affected, and IL-1β was below the limit of detection. Serum levels of C-reactive protein were also affected, increasing with some metals and decreasing with others. The TBARS assay, an assessment of lipid peroxidation, demonstrated that implanted aluminum and lead increased markers of lipid peroxidation in serum. Taken together, the results suggest that serum cytokine levels, as well as other indicators of oxidative damage, may prove useful in identifying potential adverse health effects of embedded metals.
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Eltit F, Mohammad N, Medina I, Haegert A, Duncan CP, Garbuz DS, Greidanus NV, Masri BA, Ng TL, Wang R, Cox ME. Perivascular lymphocytic aggregates in hip prosthesis-associated adverse local tissue reactions demonstrate Th1 and Th2 activity and exhausted CD8 + cell responses. J Orthop Res 2021; 39:2581-2594. [PMID: 33506972 DOI: 10.1002/jor.24998] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 01/19/2021] [Accepted: 01/24/2021] [Indexed: 02/04/2023]
Abstract
Hip implants are a successful solution for osteoarthritis; however, some individuals with metal-on-metal (MoM) and metal-on-polyethylene (MoP) prosthetics develop adverse local tissue reactions (ALTRs). While MoM and MoP ALTRs are presumed to be delayed hypersensitivity reactions to corrosion products, MoM- and MoP-associated ALTRs present with different histological characteristics. We compared MoM- and MoP-associated ALTRs histopathology with cobalt and chromium levels in serum and synovial fluid. We analyzed the gene expression levels of leukocyte aggregates and synovial fluid chemokines/cytokines to resolve potential pathophysiologic differences. In addition, we classified ALTRs from 79 patients according to their leukocyte infiltrates as macrophage-dominant, mixed, and lymphocyte-dominant. Immune-related transcript profiles from lymphocyte-dominant MoM- and MoP-associated ALTR patients with perivascular lymphocytic aggregates were similar. Cell signatures indicated predominantly macrophage, Th1 and Th2 lymphocytic infiltrate, with strong exhausted CD8+ signature, and low Th17 and B cell, relative to healthy lymph nodes. Lymphocyte-dominant ALTR-associated synovial fluid contained higher levels of induced protein 10 (IP-10), interleukin-1 receptor antagonist (IL-1RN), IL-8, IL-6, IL-16, macrophage inflammatory protein 1 (MIP-1α), IL-18, MCP-2, and lower cell-attracting chemokine levels, when compared with prosthetic revisions lacking ALTRs. In addition, the higher levels of IP-10, IL-8, IL-6, MIP-1α, and MCP-2 were observed within the synovial fluid of the lymphocyte-dominant ALTRs relative to the macrophage-dominant ALTRs. Not all cytokines/chemokines were detected in the perivascular aggregate transcripts, suggesting the existence of other sources in the affected synovia. Our results support the hypothesis of common hypersensitivity pathogenesis in lymphocyte-dominant MoM and MoP ALTRs. The exhausted lymphocyte signature indicates chronic processes and an impaired immune response, although the cause of the persistent T-cell activation remains unclear. The cytokine/chemokine signature of lymphocyte-dominant-associated ATLRs may be of utility for diagnosing this more aggressive pathogenesis.
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Affiliation(s)
- Felipe Eltit
- Department of Materials Engineering, University of British Columbia, Vancouver, British Columbia, Canada.,School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver Prostate Centre, Vancouver, British Columbia, Canada
| | - Nissreen Mohammad
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Anne Haegert
- Vancouver Prostate Centre, Vancouver, British Columbia, Canada
| | - Clive P Duncan
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald S Garbuz
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Hip Health and Mobility, Vancouver, British Columbia, Canada
| | - Nelson V Greidanus
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Hip Health and Mobility, Vancouver, British Columbia, Canada
| | - Tony L Ng
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rizhi Wang
- Department of Materials Engineering, University of British Columbia, Vancouver, British Columbia, Canada.,School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Hip Health and Mobility, Vancouver, British Columbia, Canada
| | - Michael E Cox
- Vancouver Prostate Centre, Vancouver, British Columbia, Canada.,Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Eltit F, Noble J, Sharma M, Benam N, Haegert A, Bell RH, Simon F, Duncan CP, Garbuz DS, Greidanus NV, Masri BA, Ng TL, Wang R, Cox ME. Cobalt ions induce metabolic stress in synovial fibroblasts and secretion of cytokines/chemokines that may be diagnostic markers for adverse local tissue reactions to hip implants. Acta Biomater 2021; 131:581-594. [PMID: 34192572 DOI: 10.1016/j.actbio.2021.06.039] [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: 04/07/2021] [Revised: 06/17/2021] [Accepted: 06/22/2021] [Indexed: 12/18/2022]
Abstract
Adverse local tissue reactions (ALTRs) are a prominent cause of hip implant failure. ALTRs are characterized by aseptic necrosis and leukocyte infiltration of synovial tissue. The prevalence of ALTRs in hips with failing metal implants, with highest rates occurring in patients with metal-on-metal articulations, suggests a role for CoCrMo corrosion in ALTR formation. Although hypersensitivity reactions are the most accepted etiology, the precise cellular mechanism driving ALTR pathogenesis remains enigmatic. Here we show that cobalt ions released by failing hip implants induce mitochondrial stress and cytokine secretion by synovial fibroblasts: the presumptive initiators of ALTR pathogenesis. We found that in-vitro treatment of synovial fibroblasts with cobalt, but not chromium, generated gene expression changes indicative of hypoxia and mitophagy responses also observed in ALTRs biopsies. Inflammatory factors secreted by cobalt-exposed synovial fibroblasts were among those most concentrated in ALTR synovial fluid. Furthermore, both conditioned media from cobalt-exposed synovial fibroblasts, and synovial fluid from ALTRs patients, elicit endothelial activation and monocyte migration. Finally, we identify the IL16/CTACK ratio in synovial fluid as a possible diagnostic marker of ALTRs. Our results provide evidence suggesting that metal ions induce cell stress in synovial fibroblasts that promote an inflammatory response consistent with initiating ALTR formation. STATEMENT OF SIGNIFICANCE: We demonstrate that the cytotoxic effects of cobalt ions on the synovial cells (fibroblast) is sufficient to trigger inflammation on hip joints with metal implants. Cobalt ions affect mitochondrial function, leading to the auto phagocytosis of mitochondria and trigger a hypoxic response. The cell's hypoxic response includes secretion of cytokines that are capable of trigger inflammation by activating blood vessels and enhancing leukocyte migration. Among the secreted cytokines is IL-16, which is highly concentrated in the synovial fluid of the patients with adverse local tissue reactions and could be use as diagnostic marker. In conclusion we define the cells of the hip joint as key players in triggering the adverse reactions to hip implants and providing biomarkers for early diagnosis of adverse reactions to hip implants.
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Abstract
Prosthetic loosening has been debated for decades, both in terms of the timing and nature of the triggering events. Multiple radiostereometric studies of hip prostheses have now shown that early migration poses a risk of future clinical failure, but is this enough to explain late clinical loosening?To answer this question, the progression of loosening from initiation to radiographic detection is described; and the need for explanations other than early prosthetic loosening is analysed, such as stress-shielding, particle disease, and metal sensitivity.Much evidence indicates that prosthetic loosening has already been initiated during or shortly after the surgery, and that the subsequent progression of loosening is affected by biomechanical factors, fluid pressure fluctuations and inflammatory responses to necrotic cells and cell fragments, i.e. the concept of late loosening appears to be a misinterpretation of late-detected loosening.Clinical implications: atraumatic surgery and initial prosthetic stability are crucial in ensuring low risk of prosthetic loosening. Cite this article: EFORT Open Rev 2020;5:113-117. DOI: 10.1302/2058-5241.5.190014.
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Affiliation(s)
- Bengt Mjöberg
- Department of Orthopaedics, Lund University, Lund, Sweden
- Bengt Mjöberg, Västra Vallgatan 29, SE-27135 Ystad, Sweden.
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Nyga A, Hart A, Tetley TD. Molecular analysis of HIF activation as a potential biomarker for adverse reaction to metal debris (ARMD) in tissue and blood samples. J Biomed Mater Res B Appl Biomater 2018; 107:1352-1362. [PMID: 30261121 DOI: 10.1002/jbm.b.34227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 06/14/2018] [Accepted: 08/12/2018] [Indexed: 12/25/2022]
Abstract
We aimed to find a biomarker for patients with adverse reaction to metal debris (ARMD) due to a metal-on-metal (MoM) hip implant. First, we compared molecular markers of hypoxia-inducible factor (HIF) pathway activation (BNIP3, GLUT1, HO1, VEGF, and HIF1A) and inflammatory response (IL1B and COX2) in tissue from patients undergoing revision of MoM hip implant with tissue from patients undergoing primary hip replacement (PHR). Second, we compared blood levels of the above molecular markers and additional inflammatory markers: TNFA, IL18, CASPASE1, NFKB or IKB, and TLR1-4 mRNA in patients with non-failed MoM hips. We report the presence of increased expression of HIF-target genes in the periprosthetic tissue in MoM patients when compared to the PHR group. This suggests HIF pathway activation due to MoM debris and the potential of using HIF targets as a predictor of failure. Analysis of blood samples from nonoverlapping, nonfailed, MoM group showed significantly higher expression of COX2 mRNA and significant correlations between HIF1A and GLUT1 mRNA expressions, and between HIF1A mRNA and selection of inflammatory genes, including IL18, IKB, TLR1, and TLR4. HIF pathway activation in the periprosthetic tissue biopsies of patients with hip replacements may represent the first biomarker to identify early ARMD. Further studies investigating blood biomarkers could also prove beneficial in detecting ARMD that could lead to an early intervention and improved patient outcome after hip revision surgery. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1352-1362, 2019.
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Affiliation(s)
- Agata Nyga
- Department of Pharmacology and Toxicology, National Heart & Lung Institute, Imperial College London, London, UK
| | - Alister Hart
- Institute of Orthopaedics & Musculoskeletal Science, Royal National Orthopaedic Hospital, University College London, Stanmore, UK
| | - Teresa D Tetley
- Department of Pharmacology and Toxicology, National Heart & Lung Institute, Imperial College London, London, UK
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Bertrand J, Delfosse D, Mai V, Awiszus F, Harnisch K, Lohmann CH. Ceramic prosthesis surfaces induce an inflammatory cell response and fibrotic tissue changes. Bone Joint J 2018; 100-B:882-890. [DOI: 10.1302/0301-620x.100b7.bjj-2017-1590.r2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Early evidence has emerged suggesting that ceramic-on-ceramic articulations induce a different tissue reaction to ceramic-on-polyethylene and metal-on-metal bearings. Therefore, the aim of this study was to investigate the tissue reaction and cellular response to ceramic total hip arthroplasty (THA) materials in vitro, as well as the tissue reaction in capsular tissue after revision surgery of ceramic-on-ceramic THAs. Patients and Methods We investigated tissue collected at revision surgery from nine ceramic-on-ceramic articulations. we compared our findings with tissue obtained from five metal-on-metal THA revisions, four ceramic-on-polyethylene THAs, and four primary osteoarthritis synovial membranes. The latter were analyzed to assess the amount of tissue fibrosis that might have been present at the time of implantation to enable evaluation, in relation to implantation time, of any subsequent response in the tissues. Results There was a significant increase in tissue fibrosis with implantation time for all implant types tested. Interestingly, the tissue fibrosis in ceramic-on-ceramic THAs was significantly increased compared with metal-on-metal and ceramic-on-polyethylene. Additionally, we found ceramic wear particles in the periprosthetic tissue of ceramic implants. Fibroblasts responded with expression of cytokines when cultured on alumina-toughened zirconia (ATZ) and zirconia-toughened alumina (ZTA) ceramic surfaces. This response was more pronounced on ATZ ceramics compared with ZTA ceramics. The same inflammatory response was observed with peripheral blood mononuclear cells (PBMCs) cultured on ZTA and ATZ. Conclusion Our findings therefore, corroborate the previous findings that ceramic-on-ceramic periprosthetic revision tissue is fibrous and offer an explanation for this observation. We detected a long-term inflammatory response of PBMCs and an inflammatory response of fibroblasts to ATZ and ZTA ceramic. These findings partially explain the fibrotic tissue change in periprosthetic tissue of ceramic-on-ceramic bearings. Cite this article: Bone Joint J 2018;100-B:882–90.
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Affiliation(s)
- J. Bertrand
- Department of Orthopaedic Surgery, Otto-von-Guericke
University, Magdeburg, Germany
| | | | - V. Mai
- Mathys AG Bettlach, Bettlach, Switzerland
| | - F. Awiszus
- Department of Orthopaedic Surgery, Otto-von-Guericke
University, Magdeburg, Germany
| | - K. Harnisch
- Institute for Materials and Joining Technology,
Otto-von-Guericke University, Magdeburg, Germany
| | - C. H. Lohmann
- Department of Orthopaedic Surgery, Otto-von-Guericke
University, Magdeburg, Germany
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10
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Steffen JE, Fassler EA, Reardon KJ, Egilman DS. Grave fraudulence in medical device research: a narrative review of the PIN seeding study for the Pinnacle hip system. Account Res 2017; 25:37-66. [DOI: 10.1080/08989621.2017.1405259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | - David S. Egilman
- Department of Family Medicine, Brown University, Attleboro, Massachusetts, USA
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Granchi D, Savarino LM, Ciapetti G, Baldini N. Biological effects of metal degradation in hip arthroplasties. Crit Rev Toxicol 2017; 48:170-193. [PMID: 29130357 DOI: 10.1080/10408444.2017.1392927] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metals and metal alloys are the most used materials in orthopedic implants. The focus is on total hip arthroplasty (THA) that, though well tolerated, may be associated with local and remote adverse effects in the medium-long term. This review aims to summarize data on the biological consequences of the metal implant degradation that have been attributed predominantly to metal-on-metal (MoM) THA. Local responses to metals consist of a broad clinical spectrum ranging from small asymptomatic tissue lesions to severe destruction of bone and soft tissues, which are designated as metallosis, adverse reactions to metal debris (ARMD), aseptic lymphocytic vasculitis associated lesion (ALVAL), and pseudotumors. In addition, the dissemination of metal particles and ions throughout the body has been associated with systemic adverse effects, including organ toxicity, cancerogenesis, teratogenicity, and immunotoxicity. As proved by the multitude of studies in this field, metal degradation may increase safety issues associated with THA, especially with MoM hip systems. Data collection regarding local, systemic and long-term effects plays an essential role to better define any safety risks and to generate scientifically based recommendations.
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Affiliation(s)
- Donatella Granchi
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Lucia Maria Savarino
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Gabriela Ciapetti
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Nicola Baldini
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy.,b Department of Biomedical and Neuromotor Science , University of Bologna , Bologna , Italy
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12
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Lohmann CH, Hameister R, Singh G. Allergies in orthopaedic and trauma surgery. Orthop Traumatol Surg Res 2017; 103:S75-S81. [PMID: 28043850 DOI: 10.1016/j.otsr.2016.06.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 05/26/2016] [Accepted: 06/07/2016] [Indexed: 02/02/2023]
Abstract
Hypersensitivity reactions to implants in orthopaedic and trauma surgery are a rare but devastating complication. They are considered as a delayed-type of hypersensitivity reaction (type IV), characterized by an antigen activation of sensitized T-lymphocytes releasing various cytokines and may result in osteoclast activation and bone resorption. Potential haptens are originated from metal alloys or bone-cement. A meta-analysis has confirmed a higher probability of developing a metal hypersensitivity postoperatively and noted a greater risk of failed replacements compared to stable implants. Hypersensitivity to implants may present with a variety of symptoms such as pain, joint effusion, delayed wound/bone healing, persistent secretion, allergic dermatitis (localized or systemic), clicking noises, loss of joint function, instability and failure of the implant. Various diagnostic options have been offered, including patch testing, metal alloy patch testing, histology, lymphocyte transformation test (LTT), memory lymphocyte immunostimulation assay (MELISA), leukocyte migration inhibition test (LIF) and lymphocyte activation test (LAT). No significant differences between in vivo and in vitro methods have been found. Due to unconvincing evidence for screening methods, predictive tests are not recommended for routine performance. Infectious aetiology always needs to be excluded. As there is a lack of evidence on large-scale studies with regards to the optimal treatment option, management currently relies on individual case-by-case decisions. Several options for patients with (suspected) metal-related hypersensitivity exist and may include materials based on ceramic, titanium or oxinium or modified surfaces. Promising results have been reported, but long-term experience is lacking. More large-scaled studies are needed in this context. In patients with bone-cement hypersensitivity, the component suspected for hypersensitivity should be avoided. The development of (predictive) biomarkers is considered as a major contribution for the future.
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Affiliation(s)
- C H Lohmann
- Department of Orthopaedic Surgery, Otto-von-Guericke University, 44, Leipziger Strasse, 39120 Magdeburg, Germany.
| | - R Hameister
- Department of Orthopaedic Surgery, Otto-von-Guericke University, 44, Leipziger Strasse, 39120 Magdeburg, Germany; Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, 4, Medical Drive, 117594, Singapore
| | - G Singh
- Division of Musculoskeletal Oncology, University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, 1E, Kent Ridge Road, 119228, Singapore
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13
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Banke IJ, Stade N, Prodinger PM, Mühlhofer HM, Thomas P, Thomas B, Summer B, van Griensven M, von Eisenhart-Rothe R, Gollwitzer H. [Synovial biomarkers for differential diagnosis of painful arthroplasty]. DER ORTHOPADE 2015; 44:93, 936-8, 940-1. [PMID: 26542406 DOI: 10.1007/s00132-015-3188-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The diagnosis and treatment of periprosthetic joint infection (PJI) remain true clinical challenges. PJI diminishes therapeutic success, causes dissatisfaction for the patient and medical staff, and often requires extensive surgical revision(s). At the present time, an extensive multimodal algorithmic approach is used to avoid time- and cost-consuming diagnostic aberrations. However, especially in the case of the frequent and clinically most relevant "low-grade" PJI, the current diagnostic "gold standard" has reached its limits. EVALUATION Synovial biomarkers are thought to close this diagnostic gap, hopefully enabling the safe differentiation among aseptic, (chronic) septic, implant allergy-related and the arthrofibrotic genesis of symptomatic arthroplasty. Therefore, joint aspiration for obtaining synovial fluid is preferred over surgical synovial tissue biopsy because of the faster results, greater practicability, greater patient safety, and lower costs. In addition to the parameters synovial IL-6, CRP, and leukocyte esterase, novel biomarkers such as antimicrobial peptides and other proinflammatory cytokines are currently highlighted because of their very high to excellent diagnostic accuracy. CONCLUSION Independent multicenter validation studies are required to show whether a set of different innovative synovial fluid biomarkers rather than a few single parameters is favorable for a safe "one-stop shop" differential diagnosis of PJI.
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Affiliation(s)
- I J Banke
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - N Stade
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - P M Prodinger
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - H M Mühlhofer
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - P Thomas
- Klinik und Poliklinik für Dermatologie und Allergologie der LMU München, Frauenlobstraße 9-11, 80337, München, Deutschland
| | - B Thomas
- Klinik und Poliklinik für Dermatologie und Allergologie der LMU München, Frauenlobstraße 9-11, 80337, München, Deutschland
| | - B Summer
- Klinik und Poliklinik für Dermatologie und Allergologie der LMU München, Frauenlobstraße 9-11, 80337, München, Deutschland
| | - M van Griensven
- Experimentelle Unfallchirurgie, Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - R von Eisenhart-Rothe
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - H Gollwitzer
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland.,ATOS Klinik München, Effnerstr. 38, 81925, München, Deutschland
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