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Leal J, Holland CT, Cochrane NH, Seyler TM, Jiranek WA, Wellman SS, Bolognesi MP, Ryan SP. The relationship between pseudotumours and infected complications in patients who have undergone metal-on-metal total hip arthroplasty. Bone Joint J 2024; 106-B:555-564. [PMID: 38821507 DOI: 10.1302/0301-620x.106b6.bjj-2023-1370.r1] [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] [Indexed: 06/02/2024]
Abstract
Aims This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection. Methods A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years' clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery. Results The rate of PJI for all identified MoM THAs was 3.5% (41/1,171), with a mean follow-up of 10.9 years (2.0 to 20.4). Of the patients included in the final cohort, 8.2% (27/328) had PJI, with a mean follow-up of 12.2 years (2.3 to 20.4). Among this cohort, 31.1% (102/328) had a history of pseudotumour. The rate of PJI in these patients was 14.7% (15/102), which was greater than those without pseudotumour, 5.3% (12/226) (p = 0.008). Additionally, logistic regression analysis showed an association between history of pseudotumour and PJI (odds ratio 4.36 (95% confidence interval 1.77 to 11.3); p = 0.002). Optimal diagnostic cutoffs for PJI in patients with history of pseudotumour versus those without were 33.1 mm/hr and 24.5 mm/hr for ESR and 7.37 mg/dl and 1.88 mg/dl for CRP, respectively. Conclusion Patients with history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. While suspicion of infection should be high for these patients, ESR and CRP cutoffs published by the European Bone and Joint Infection Society may not be appropriate for patients with a history of pseudotumour, as ESR and CRP levels suggestive of PJI are likely to be higher than for those without a pseudotumour. Additional investigation, such as aspiration, is highly recommended for these patients unless clinical suspicion and laboratory markers are low.
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Affiliation(s)
- Justin Leal
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | | | - Niall H Cochrane
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - William A Jiranek
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
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Fortmann C, Göen T, Wiesner S, Hegermann J, Kiblawi R, Dohna M, Ure BM, Renz DM, Petersen C, Kuebler JF. Titanium nitride coating of pectus bar increases metal contamination after minimally-invasive repair of pectus excavatum. PLoS One 2023; 18:e0292616. [PMID: 37824548 PMCID: PMC10569521 DOI: 10.1371/journal.pone.0292616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
INTRODUCTION Previous studies demonstrated a release of toxic metals, e.g. nickel and chromium, from stainless steel bars used for minimally invasive repair of pectus excavatum (MIRPE). In the present study, we investigated the impact of titanium nitride coating on the metal release and exposure of MIRPE patients. MATERIAL AND METHODS We analyzed the courses of nickel and chromium levels in blood, urine and local tissue in patients undergoing MIRPE with a titanium nitride coated pectus bar between 03/2017 and 10/2018. Sample collection was scheduled prior to MIRPE, at defined postoperative time points and at bar removal. Additionally, we evaluated irritative symptoms. Results were compared to a control group who received uncoated stainless steel bars in a previous time period (03/2015-02/2017). RESULTS 12 patients received coated pectus bars (mean age 15.7 years). The control group included 28 patients. After implantation of a titanium nitride coated bar, significant increase in systemic nickel and chromium levels after one, two and three years was noted. In an interim analysis one year after MIRPE, we observed patients with coated bars to have significantly elevated trace metal values compared to the control group. This elevation persisted throughout the observation period. Tissue metal values were also significantly increased. Irritative symptoms occurred significantly more often in study patients compared to controls (50.0% vs. 14.3%). CONCLUSIONS Coating of pectus bars with titanium nitride failed to reduce metal contamination after MIRPE. Instead, it resulted in a significant increase of trace metal levels after MIRPE, compared to patients with stainless steel bars, which may be explained by wear of the coating and inter-component mobilization processes.
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Affiliation(s)
- Caroline Fortmann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Thomas Göen
- Social and Environmental Medicine, Institute and Outpatient Clinic of Occupational, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Soeren Wiesner
- Hannover Medical School, Institute for Biostatistics, Hannover, Germany
| | - Jan Hegermann
- Hannover Medical School, Research Core Unit Electron Microscopy, Institute of Functional and Applied Anatomy, Hannover, Germany
| | - Rim Kiblawi
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Martha Dohna
- Department of Pediatric Radiology, Hannover Medical School, Institute of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Benno M. Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Diane Miriam Renz
- Department of Pediatric Radiology, Hannover Medical School, Institute of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim F. Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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Wu D, Bhalekar RM, Marsh JS, Langton DJ, Stewart AJ. Periarticular metal hypersensitivity complications of hip bearings containing cobalt-chromium. EFORT Open Rev 2022; 7:758-771. [PMID: 36475551 PMCID: PMC9780614 DOI: 10.1530/eor-22-0036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hip joints with bearings composed of cobalt-chromium alloy (metal-on-metal bearings) have been one of the most widely used implants in joint replacement arthroplasty. Unfortunately, these implants can contribute to a complication called aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL), a type IV metal hypersensitivity response around the joint. Consistent with such bearings, increased metal debris can be found in the surrounding fluids and in remote tissues and organs, due to wear and corrosion. It is hypothesized that metal ions released from the prosthesis (including Co2+) can potentially form haptens with proteins such as serum albumin in synovial fluid that in turn elicit ALVAL. Generally, elevated cobalt and chromium levels in synovial fluids may indicate implant failure. However, such measurements cannot be used as a reliable tool to predict the onset of ALVAL. To detect ALVAL, some diagnostic tests, questionnaires and imaging techniques have been used clinically with some success, but a standardized approach is lacking. At present, guidelines for implant usage and patient management are ambiguous and inconsistent across health care authorities. To reduce and better manage the development of ALVAL, further research into the precise molecular mechanism(s) by which ALVAL develops is urgently needed. Identification of diagnostic and prognostic biomarkers for ALVAL is required, as are more standardized guidelines for surgery and patient management.
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Affiliation(s)
- Dongmei Wu
- School of Medicine, University of St. Andrews, St. Andrews, Fife, United Kingdom
| | - Rohan M Bhalekar
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, United Kingdom
| | - Jordan S Marsh
- School of Medicine, University of St. Andrews, St. Andrews, Fife, United Kingdom
| | - David J Langton
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, United Kingdom
| | - Alan J Stewart
- School of Medicine, University of St. Andrews, St. Andrews, Fife, United Kingdom,Correspondence should be addressed to A J Stewart;
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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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Gómez-Arnaiz S, Tate RJ, Grant MH. Cobalt Neurotoxicity: Transcriptional Effect of Elevated Cobalt Blood Levels in the Rodent Brain. TOXICS 2022; 10:toxics10020059. [PMID: 35202246 PMCID: PMC8878729 DOI: 10.3390/toxics10020059] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 12/11/2022]
Abstract
Metal-on-metal (MoM) hip implants made of cobalt chromium (CoCr) alloy have shown early failure compared with other bearing materials. A consequence of the abnormal wear produced by these prostheses is elevated levels of cobalt in the blood of patients, which can lead to systemic conditions involving cardiac and neurological symptoms. In order to better understand the implications for patients with these implants, we carried out metal content and RNA-Seq analysis of excised tissue from rats treated intraperitonially for 28 days with low concentrations of cobalt. Cobalt blood levels in dosed rats were found to be similar to those seen in some patients with MoM implants (range: 4–38 μg/L Co in blood). Significant accumulation of cobalt was measured in a range of tissues including kidney, liver, and heart, but also in brain tissue. RNA-Seq analysis of neural tissue revealed that exposure to cobalt induces a transcriptional response in the prefrontal cortex (pref. cortex), cerebellum, and hippocampus. Many of the most up- and downregulated genes appear to correspond to choroid plexus transcripts. These results indicate that the choroid plexus could be the brain tissue most affected by cobalt. More specifically, the differentially expressed genes show a disruption of steroidogenesis and lipid metabolism. Several other transcripts also demonstrate that cobalt induces an immune response. In summary, cobalt exposure induces alterations in the brain transcriptome, more specifically, the choroid plexus, which is in direct contact with neurotoxicants at the blood–cerebrospinal fluid barrier.
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Affiliation(s)
- Sara Gómez-Arnaiz
- Wolfson Centre, Biomedical Engineering Department, University of Strathclyde, Glasgow G4 0NW, UK;
| | - Rothwelle J. Tate
- Strathclyde Institute for Pharmacy & Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK;
| | - Mary Helen Grant
- Wolfson Centre, Biomedical Engineering Department, University of Strathclyde, Glasgow G4 0NW, UK;
- Correspondence:
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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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Agarwala S, Vijayvargiya M. Predictive factors affecting long-term survivorship of ASR metal-on-metal total hip arthroplasty. SICOT J 2021; 7:51. [PMID: 34668856 PMCID: PMC8527991 DOI: 10.1051/sicotj/2021040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/14/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION We present the outcome of 154 ASR (Articular Surface Replacement) hips performed at the P.D Hinduja Hospital and Medical Research Centre in terms of revision rate, metal ion levels, and factors affecting survivorship. Further, determined the importance of serial metal ion estimation over single value with poorly functioning arthroplasties. METHODS A retrospective study of 154 ASR arthroplasties (136 patients) performed from April 2005 till March 2010 was conducted. Ninety-seven patients were available for final analysis. All patients were assessed for symptoms, radiographs, blood metal (chromium and cobalt), metal artefact reduction sequence (MARS), magnetic resonance imaging (MRI), and computerized tomography (CT). RESULTS Female gender, smaller femoral head, patients with a rising level of metal ion levels were more likely to have revision surgery. However, abnormal acetabular inclination/anteversion was not associated with the occurrence of raised metal ion levels, ARMD (adverse reaction to metal debris) or revision surgery. Patients with raised metal ion levels were more likely to have periprosthetic lucency, ARMD, and revision surgery. Median metal levels increased initially for the first three years. Still, patients who required revision surgery continued to have a metal ion rise until the point when revision surgery was performed. In contrast, patients who had a fall in metal ion levels did not require revision. CONCLUSION A single metal ion value is less predictive of failing arthroplasties; instead, a rising trend of metal ion levels can better delineate arthroplasties which will require revision. ASR hips whose blood ion levels fell after an initial rise and showed a declining trend did well.
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Affiliation(s)
- Sanjay Agarwala
- Chief of Surgery and Director Professional Services, P.D Hinduja Hospital and Medical Research Centre, 400016 Mumbai, India
| | - Mayank Vijayvargiya
- Junior Consultant, Department of Orthopedics, P.D Hinduja Hospital and Medical Research Centre, 400016 Mumbai, India
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Zheng F, Li Y, Zhang F, Sun Y, Zheng C, Luo Z, Wang YL, Aschner M, Zheng H, Lin L, Cai P, Shao W, Guo Z, Zheng M, Zhou XZ, Lu KP, Wu S, Li H. Cobalt induces neurodegenerative damages through Pin1 inactivation in mice and human neuroglioma cells. JOURNAL OF HAZARDOUS MATERIALS 2021; 419:126378. [PMID: 34175703 DOI: 10.1016/j.jhazmat.2021.126378] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/29/2021] [Accepted: 06/08/2021] [Indexed: 06/13/2023]
Abstract
Cobalt is a hazardous material that has harmful effects on neurotoxicity. Excessive exposure to cobalt or inactivation of the unique proline isomerase Pin1 contributes to age-dependent neurodegeneration. However, nothing is known about the role of Pin1 in cobalt-induced neurodegeneration. Here we find that out of several hazardous materials, only cobalt dose-dependently decreased Pin1 expression and alterations in its substrates, including cis and trans phosphorylated Tau in human neuronal cells, concomitant with neurotoxicity. Cobalt-induced neurotoxicity was aggravated by Pin1 genetic or chemical inhibition, but rescued by Pin1 upregulation. Furthermore, less than 4 μg/l of blood cobalt induced dose- and age-dependent Pin1 downregulation in murine brains, ensuing neurodegenerative changes. These defects were corroborated by changes in Pin1 substrates, including cis and trans phosphorylated Tau, amyloid precursor protein, β amyloid and GSK3β. Moreover, blood Pin1 was downregulated in human hip replacement patients with median blood cobalt level of 2.514 μg/l, which is significantly less than the safety threshold of 10 μg/l, suggesting an early role Pin1 played in neurodegenerative damages. Thus, Pin1 inactivation by cobalt contributes to age-dependent neurodegeneration, revealing that cobalt is a hazardous material triggering AD-like neurodegenerative damages.
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Affiliation(s)
- Fuli Zheng
- Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Fujian Provincial Key Laboratory of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; The Key Laboratory of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Yuqing Li
- Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Fengshun Zhang
- Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Yi Sun
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Chunyan Zheng
- Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Zhousong Luo
- Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Yuan-Liang Wang
- Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Fujian Provincial Key Laboratory of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; The Key Laboratory of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - Hong Zheng
- Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou 350007, China
| | - Liqiong Lin
- Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou 350007, China
| | - Ping Cai
- Fujian Provincial Key Laboratory of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; The Key Laboratory of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Department of Health Inspection and Quarantine, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Wenya Shao
- Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Fujian Provincial Key Laboratory of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; The Key Laboratory of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Zhenkun Guo
- Fujian Provincial Key Laboratory of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; The Key Laboratory of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou 350122, China
| | - Min Zheng
- Institute for Translational Medicine, Fujian Medical University, Fuzhou 350122, China
| | - Xiao Zhen Zhou
- Division of Translational Therapeutics, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Kun Ping Lu
- Division of Translational Therapeutics, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Siying Wu
- Fujian Provincial Key Laboratory of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; The Key Laboratory of Environment and Health, 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.
| | - Huangyuan Li
- Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou 350122, China; Fujian Provincial Key Laboratory of Environmental Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou 350122, China; The Key Laboratory of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou 350122, China.
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Perino G, De Martino I, Zhang L, Xia Z, Gallo J, Natu S, Langton D, Huber M, Rakow A, Schoon J, Gomez-Barrena E, Krenn V. The contribution of the histopathological examination to the diagnosis of adverse local tissue reactions in arthroplasty. EFORT Open Rev 2021; 6:399-419. [PMID: 34267931 PMCID: PMC8246109 DOI: 10.1302/2058-5241.6.210013] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The histopathological examination of the periprosthetic soft tissue and bone has contributed to the identification and description of the morphological features of adverse local tissue reactions (ALTR)/adverse reactions to metallic debris (ARMD). The need of a uniform vocabulary for all disciplines involved in the diagnosis and management of ALTR/ARMD and of clarification of the parameters used in the semi-quantitative scoring systems for their classification has been considered a pre-requisite for a meaningful interdisciplinary evaluation. This review of key terms used for ALTR/ARMD has resulted in the following outcomes: (a) pseudotumor is a descriptive term for ALTR/ARMD, classifiable in two main types according to its cellular composition defining its clinical course; (b) the substitution of the term metallosis with presence of metallic wear debris, since it cannot be used as a category of implant failure or histological diagnosis; (c) the term aseptic lymphocytic-dominated vasculitis- associated lesion (ALVAL) should be replaced due to the absence of a vasculitis with ALLTR/ALRMD for lymphocytic-predominant and AMLTR/AMRMD for macrophage-predominant reaction. This review of the histopathological classifications of ALTR/ARMD has resulted in the following outcomes: (a) distinction between cell death and tissue necrosis; (b) the association of corrosion metallic debris with adverse local lymphocytic reaction and tissue necrosis; (c) the importance of cell and particle debris for the viscosity and density of the lubricating synovial fluid; (d) a consensus classification of lymphocytic infiltrate in soft tissue and bone marrow; (e) evaluation of the macrophage infiltrate in soft tissues and bone marrow; (f) classification of macrophage induced osteolysis/aseptic loosening as a delayed type of ALTR/ARMD; (g) macrophage motility and migration as possible driving factor for osteolysis; (h) usefulness of the histopathological examination for the natural history of the adverse reactions, radiological correlation, post-marketing surveillance, and implant registries. The review of key terms used for the description and histopathological classification of ALTR/ARMD has resulted in a comprehensive, new standard for all disciplines involved in their diagnosis, clinical management, and long-term clinical follow-up.
Cite this article: EFORT Open Rev 2021;6:399-419. DOI: 10.1302/2058-5241.6.210013
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Affiliation(s)
- Giorgio Perino
- Department of Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Ivan De Martino
- Division of Orthopaedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Lingxin Zhang
- Department of Pathology and Laboratory Medicine, Sinai Health System, Toronto, Canada
| | - Zhidao Xia
- Centre for Nanohealth, Swansea University Medical School, Singleton Park, Swansea, UK
| | - Jiri Gallo
- Department of Orthopaedics, Faculty of Medicine and Dentistry, University Hospital, Palacky University Olomouc, Czech Republic
| | - Shonali Natu
- Department of Pathology, University Hospital of North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
| | - David Langton
- Orthopaedic Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Monika Huber
- Pathologisch-bakteriologisches Institut, Otto Wagner Spital, Wien, Austria
| | - Anastasia Rakow
- Department of Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Janosch Schoon
- Department of Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Enrique Gomez-Barrena
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario La Paz-IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
| | - Veit Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik-GmbH, Trier, Germany
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10
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Comparison of the long-term cause of failure and survivorship of four hundred and twenty seven metal-on-metal hip arthroplasties: resurfacing versus large head total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2021; 45:3075-3081. [PMID: 34155524 PMCID: PMC8626394 DOI: 10.1007/s00264-021-05044-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/12/2021] [Indexed: 12/20/2022]
Abstract
Introduction Comparison of mid- to long-term cause of failure and survivorship of metal-on-metal (MoM) resurfacing hip arthroplasty (RHA) and large head total hip arthroplasty (THA) remains sparse. This study aimed to identify and compare the cause of failure and survivorship of MoM RHA and THA at a minimum ten year follow-up. Methods Four hundred twenty-seven MoM hip arthroplasties (286 THA and 141 RHA) were retrospectively analyzed at a mean follow-up of 13 ± three years. Causes of failure were reported as MoM specific (i.e., adverse reaction to metal debris (ARMD) and painful hip with ion elevation) or MoM non-specific (i.e., fracture, infection, and dislocation). Chromium (Cr) and cobalt (Co) ion levels and Co/Cr ratio were compared. Survivorship was compared according to the cause of failure with revision as the endpoint. Results The rate of ARMD was significantly higher in THA (OR = 2.9 [95%-CI: 1–7]; p = 0.02). No significant difference was detected in failure rate due to other causes between the two groups (p = 0.2–0.9). Ion levels and Co/Cr ratio were both significantly higher in THA (p < 0.01). Survivorship was significantly lower in THA compared to RHA at ten years [89% (95%-CI: 85%–91%) vs 96% (95%-CI: 91%–98%); p = 0.01] and 15 years [73% (95%-CI: 67%–78%) vs 83% (95%-CI: 73%–90%); p = 0.01]. Conclusion RHA survivorship was significantly higher at any time point. Failure rate due to ARMD was significantly higher in THA while no significant difference in other causes of failure was observed between the two groups. This result emphasizes the role of fretting corrosion at the head-neck junction (i.e., trunnionosis) with significantly higher ion levels and Co/Cr ratio dissociation in THA.
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11
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Whole blood chromium concentration is very rarely elevated independently of whole blood cobalt. Sci Rep 2021; 11:12352. [PMID: 34117287 PMCID: PMC8196186 DOI: 10.1038/s41598-021-91512-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 05/19/2021] [Indexed: 11/21/2022] Open
Abstract
Due to the risk of adverse reactions to metal debris resulting from increased wear of the arthroplasty more than one million metal-on-metal (MoM) hip replacements worldwide are in active follow-up. Follow-up usually includes measurement of both whole blood cobalt (Co) and chromium (Cr) concentrations. Our experience is that Cr is seldom independently elevated. We wanted to ascertain whether blood Cr measurements could be omitted from follow-up protocols without lowering the quality of follow-up. We identified 8438 whole blood Co and Cr measurements performed without or prior to revision surgery. When the cut-off levels 5 µg/L and 7 µg/L were used, Cr was independently elevated in only 0.5% (95% confidence interval, CI, 0.3 to 0.6) and 0.2% (CI 0.1 to 0.3) of the measurements. The models with continuous variables showed that the higher the blood metal concentrations are the lower the percentage of measurements with Cr higher than Co. Our results suggest that whole blood Cr is very rarely independently elevated and therefore the authorities should consider omitting Cr measurements from their screening guidelines of MoM hip replacements. We believe this change in practice would simplify follow-up and lead to cost savings without decreasing the quality of follow-up.
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Jenkinson MRJ, Meek RMD, Tate R, MacMillan S, Grant MH, Currie S. Cobalt-induced cardiomyopathy - do circulating cobalt levels matter? Bone Joint Res 2021; 10:340-347. [PMID: 34053230 PMCID: PMC8242681 DOI: 10.1302/2046-3758.106.bjr-2020-0414.r2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Elevated levels of circulating cobalt ions have been linked with a wide range of systemic complications including neurological, endocrine, and cardiovascular symptoms. Case reports of patients with elevated blood cobalt ions have described significant cardiovascular complications including cardiomyopathy. However, correlation between the actual level of circulating cobalt and extent of cardiovascular injury has not previously been performed. This review examines evidence from the literature for a link between elevated blood cobalt levels secondary to metal-on-metal (MoM) hip arthroplasties and cardiomyopathy. Correlation between low, moderate, and high blood cobalt with cardiovascular complications has been considered. Elevated blood cobalt at levels over 250 µg/l have been shown to be a risk factor for developing systemic complications and published case reports document cardiomyopathy, cardiac transplantation, and death in patients with severely elevated blood cobalt ions. However, it is not clear that there is a hard cut-off value and cardiac dysfunction may occur at lower levels. Clinical and laboratory research has found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. Further work needs to be done to clarify the link between severely elevated blood cobalt ions and cardiomyopathy. Cite this article: Bone Joint Res 2021;10(6):340–347.
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Affiliation(s)
| | | | - Rothwell Tate
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | | | - M Helen Grant
- Biomedical Engineering, University of Strathclyde, Glasgow, UK
| | - Susan Currie
- Biomedical Engineering, University of Strathclyde, Glasgow, UK
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Pogliacomi F, Schiavi P, Calderazzi F, Leigheb M, Domenichini M, Pedrazzini A, Ceccarelli F, Vaienti E. Is there a relation between clinical scores and serum ion levels after MoM-THA? One year results in 383 implants. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020014. [PMID: 33559629 PMCID: PMC7944688 DOI: 10.23750/abm.v91i14-s.10955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 11/15/2020] [Indexed: 12/14/2022]
Abstract
Background and aim of the work: Adverse reaction to metal debris is the major cause of the high revision rates of metal on metal hip implants with femoral head size ≥ 36mm. Health authorities recommend regular surveillance even for asymptomatic individuals. The main investigations used are Co+ and Cr+ serum levels, x-rays and, eventually, ultrasound and MARS-MRI. Clinic is also assessed. The aim of this study is to identify if there is a relation between ion levels and the clinical scores in order to evaluate the outcome and plan the correct management after this type of implant. Methods: 383 subjects were included and divided in 3 groups (serum ion levels >, < and >60 µg/L). Co+, Cr+, HHS and OHS results of 1 year (2017) were analysed in order to show a correlation between ion levels and clinical scores. Results: Clinical scores were similar in group 1 and 2. Differences were observed comparing the group 1 and 2 with group 3 for both variables. Discussion and Conclusions: Surveillance algorithms have been introduced by health authorities. Nevertheless, the indication to revision surgery is not simple especially in those cases in which a discrepancy between clinic and investigations is present. In this study clinical scores seem to be less important than ion levels in the evaluation of outcomes and in order to plan the correct management in the majority of cases. Larger studies are needed to highlight the real importance of clinical scores in the decision making after these type of implants.
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Affiliation(s)
- Francesco Pogliacomi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Paolo Schiavi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Filippo Calderazzi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Massimiliano Leigheb
- Department of Health Sciences, University of Eastern Piedmont (UPO) Orthopaedics and Traumatology Unit, "Maggiore della Carità" Hospital, Novara, Italy.
| | - Marco Domenichini
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | | | - Francesco Ceccarelli
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Enrico Vaienti
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
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Pozzuoli A, Berizzi A, Crimì A, Belluzzi E, Frigo AC, Conti GD, Nicolli A, Trevisan A, Biz C, Ruggieri P. Metal Ion Release, Clinical and Radiological Outcomes in Large Diameter Metal-on-Metal Total Hip Arthroplasty at Long-Term Follow-Up. Diagnostics (Basel) 2020; 10:diagnostics10110941. [PMID: 33198180 PMCID: PMC7698262 DOI: 10.3390/diagnostics10110941] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 02/08/2023] Open
Abstract
Total hip arthroplasty (THA) with metal-on-metal (MoM) bearings have shown problems of biocompatibility linked to metal ion release at the local level causing an adverse reaction to metal debris (ARMD) and at a systemic level. The aim of this study was to evaluate clinical and radiological outcomes, and metal ion concentrations in the blood and urine of patients who underwent THA with the LIMA Met-Met hip system. Patients with ceramic-on-ceramic (CoC) bearings were included as a control group. In this study, 68 patients were enrolled: 34 with MoM THAs and 34 with CoC THAs. Patients were evaluated clinically (Harris Hip Score, SF-36) and radiologically at a median of 7.4 years after surgery. Whole blood and urinary cobalt and chromium levels were also assessed. Both types of implants were comparable in terms of clinical and functional results. Ion levels were significantly higher in the MoM group compared with CoC group 7 years after surgery. No correlations were found between metal ion levels and patient demographics, functional and radiological outcomes, and prosthesis features. Patient monitoring is thus advised to establish if prosthesis revision is necessary, especially in the case of MoM THA.
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Affiliation(s)
- Assunta Pozzuoli
- Laboratory of Musculoskeletal Pathology and Oncology, Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
- Correspondence: (A.P.); (E.B.); Tel.: +39-0498213348 (A.P. & E.B.)
| | - Antonio Berizzi
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
| | - Alberto Crimì
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
| | - Elisa Belluzzi
- Laboratory of Musculoskeletal Pathology and Oncology, Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
- Correspondence: (A.P.); (E.B.); Tel.: +39-0498213348 (A.P. & E.B.)
| | - Anna Chiara Frigo
- Epidemiology and Public Health Unit, Department of Cardiac Thoracic Vascular Sciences and Public Health, Biostatistics, University of Padova, Via Loredan 18, 35131 Padova, Italy;
| | - Giorgio De Conti
- Department of Radiology, University Hospital of Padova, Via Giustiniani 2, 35128 Padova, Italy;
| | - Annamaria Nicolli
- Laboratory of Industrial Toxicology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (A.N.); (A.T.)
| | - Andrea Trevisan
- Laboratory of Industrial Toxicology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (A.N.); (A.T.)
| | - Carlo Biz
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
| | - Pietro Ruggieri
- Orthopaedic and Traumatologic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (A.B.); (A.C.); (C.B.); (P.R.)
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Gómez-Arnaiz S, Tate R, Grant M. Cytotoxicity of cobalt chloride in brain cell lines - a comparison between astrocytoma and neuroblastoma cells. Toxicol In Vitro 2020; 68:104958. [DOI: 10.1016/j.tiv.2020.104958] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/15/2020] [Accepted: 07/27/2020] [Indexed: 12/17/2022]
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Qin HM, Herrera D, Liu DF, Chen CQ, Nersesyan A, Mišík M, Knasmueller S. Genotoxic properties of materials used for endoprostheses: Experimental and human data. Food Chem Toxicol 2020; 145:111707. [PMID: 32889016 DOI: 10.1016/j.fct.2020.111707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/13/2020] [Accepted: 08/22/2020] [Indexed: 12/28/2022]
Abstract
Approximately 2 million endoprostheses are implanted annually and metal ions as well as particles are released into the body from the materials which are used. This review describes the results of studies concerning genotoxic damage caused by artificial joints. DNA damage leads to various adverse long-term health effects in humans including cancer. Experiments with mammalian cells showed that metal ions and particles from orthopedic materials cause DNA damage. Induction of chromosomal aberrations (CA) was found in several in vitro experiments and in studies with rodents with metals from orthopedic materials. Human studies focused mainly on induction of CA (7 studies). Only few investigations (4) concerned sister chromatid exchanges, oxidative DNA damage (2) and micronucleus formation (1). CA are a reliable biomarker for increased cancer risks in humans) and were increased in all studies in patients with artificial joints. No firm conclusion can be drawn at present if the effects in humans are due to oxidative stress and if dissolved metal ions or release particles play a role. Our findings indicate that patients with artificial joints may have increased cancer risks due to damage of the genetic material. Future studies should be performed to identify safe materials and to study the molecular mechanisms in detail.
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Affiliation(s)
- Hong-Min Qin
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Denise Herrera
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Dian-Feng Liu
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Chao-Qian Chen
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Armen Nersesyan
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Miroslav Mišík
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Siegfried Knasmueller
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria.
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Pietiläinen S, Mäntymäki H, Vahlberg T, Reito A, Eskelinen A, Lankinen P, Mäkelä K. Repeated cobalt and chromium ion measurements in patients with bilateral large-diameter head metal-on-metal ReCap-M2A-Magnum total hip replacement. Acta Orthop 2020; 91:378-382. [PMID: 32285731 PMCID: PMC8023891 DOI: 10.1080/17453674.2020.1751940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Whole-blood (WB) chromium (Cr) and cobalt (Co) measurements are vital in the follow-up of metal-on-metal total hip replacement (MoM THR) patients. We examined whether there is a substantial change in repeated WB, Co, and Cr levels in patients with bilateral ReCap-M2A-Magnum THR. We also specified the number of patients exceeding the safe upper limit (SUL) of WB Co and Cr in the repeated measurement.Patients and methods - We identified 141 patients with bilateral ReCap-M2A-Magnum THR operated in our institution. 61 patients had repeated WB metal ion measurements with bilateral MoM implants still in situ in the second measurement. The mean time elapsing from the first measurement (initial measurement) to the second (control measurement) was 1.9 years (SD = 0.6, range 0.2-3.5). We used earlier established SUL levels for bilateral implants by Van Der Straeten et al. (2013).Results - The median (range) Co and Cr values decreased in the repeated measurement from 2.7 (0.6-25) to 2.1 (0.5-21) and 2.6 (0.8-14) to 2.1 (0.5-18) respectively. In 13% of the patients Co levels exceeded the SUL in the initial measurement and the proportion remained constant, at 13%, in the repeated measurement. In 5% of the patients, Cr levels were above SUL in the initial measurement and an equal 5% in the control measurement.Interpretation - Repeated WB metal ion levels did not increase in patients with bilateral ReCap-M2A-Magnum THR with a mean 1.9-year measurement interval. Long-term development of WB metal ion levels is still unclear in these patients.
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Affiliation(s)
- Sakari Pietiläinen
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku
| | - Heikki Mäntymäki
- Department of Orthopaedics, Tampere University Hospital and University of Turku
| | | | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | - Petteri Lankinen
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku
| | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku
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Development, validation and application of an inductively coupled plasma – mass spectrometry method to determine cobalt in metal-on-metal prosthesis patients using volumetric absorptive microsampling. Talanta 2020; 208:120055. [DOI: 10.1016/j.talanta.2019.06.055] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/09/2019] [Accepted: 06/13/2019] [Indexed: 11/20/2022]
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Reiner T, Klotz MC, Seelmann K, Hertzsch F, Innmann MM, Streit MR, Nees TA, Moradi B, Merle C, Kretzer JP, Gotterbarm T. Long-Term Results of a Second-Generation, Small-Diameter, Metal-On-Metal Bearing in Primary Total Hip Arthroplasty at 14-year Follow-Up. MATERIALS 2020; 13:ma13030557. [PMID: 31991553 PMCID: PMC7040657 DOI: 10.3390/ma13030557] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/13/2020] [Accepted: 01/20/2020] [Indexed: 12/12/2022]
Abstract
(1) Background: The objective of the present study was to review the clinical and radiological results of a small-head, MoM bearing in primary THA and to determine blood metal ion levels at long-term follow-up. (2) Methods: We retrospectively evaluated the clinical and radiological results of 284 small-diameter, MoM 28-mm Metasul THA at a mean follow-up of 14.5 years, and measured blood metal ion concentrations in 174 of these patients. (3) Results: After 14 years, survival free for revision due to any reason was 94%. Proximal femoral osteolysis was seen in 23% of hips, and MRI demonstrated ARMD in 27 of the 66 investigated hips (41%). Mean cobalt, chromium, and titanium ion concentrations were 0.82 µg/L (range 0.22-4.45), 1.51 µg/L (0.04-22.69), and 2.68 µg/L (0.26-19.56) in patients with unilateral THA, and 2.59 µg/L (0.43-24.75), 2.50 µg/L (0.26-16.75), and 3.76 µg/L (0.67-19.77), respectively in patients with bilateral THA. Twenty-nine percent of patients showed cobalt or chromium ion levels > 2 µg/L. (4) Conclusions: Despite good clinical long-term results, increased blood metal ion levels (cobalt or chromium > 2 µg/L) were found in approximately one-third of asymptomatic patients, and proximal femoral osteolysis and ARMD were frequently seen in this cohort. Blood metal ion analysis appears helpful in the long-term follow-up of these patients in order to identify individuals at risk. In accordance with contemporary consensus statements, symptomatic patients with elevated metal ion levels and/or progressive osteolysis should be considered for additional CT or MARS MRI to determine the extent of soft tissue affection prior to revision surgery. Further studies are necessary to investigate the clinical relevance of ARMD in asymptomatic patients with small-head, MoM THA.
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Affiliation(s)
- Tobias Reiner
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
- Correspondence: ; Tel.: +49-6221-5634803; Fax: +49-6221-5626360
| | - Matthias C. Klotz
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Kirsten Seelmann
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Fabian Hertzsch
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Moritz M. Innmann
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Marcus R. Streit
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Timo A. Nees
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Babak Moradi
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Christian Merle
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
| | - Jan Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, 69118 Heidelberg, Germany;
| | - Tobias Gotterbarm
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany; (M.C.K.); (K.S.); (F.H.); (M.M.I.); (M.R.S.); (T.A.N.); (B.M.); (C.M.); (T.G.)
- Department of Orthopedics, Kepler University Hospital, Krankenhausstr. 7a, 4020 Linz, Austria
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The Ototoxic Potential of Cobalt From Metal-on-Metal Hip Implants: Objective Auditory and Vestibular Outcome. Ear Hear 2020; 41:217-230. [DOI: 10.1097/aud.0000000000000747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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21
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Hughes L, Chamberlain K, Robinson H, Sloan A, Choudry Q. Follow-up of Metal-on-Metal Hip Replacements at a Large District Hospital and the Implementation of Medicines and Healthcare Products Regulatory Agency Guidelines: A Review of 297 Patients. Clin Orthop Surg 2019; 11:403-408. [PMID: 31788162 PMCID: PMC6867927 DOI: 10.4055/cios.2019.11.4.403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/21/2019] [Indexed: 12/04/2022] Open
Abstract
Background Medicines and Healthcare products Regulatory Agency (MHRA) guidance for patients with metal-on-metal (MoM) hip replacements was provided in 2012 and updated in 2017 to assist in the early detection of soft-tissue reactions due to metal wear debris. A large number of MoM hip replacements were undertaken at our hospital trust. A program of recall for all patients with MoM hip replacements was undertaken and MHRA guidelines were implemented. In this study, we aimed to investigate the effectiveness of the revised MHRA guidelines in the detection of early adverse reactions to metal debris and to re-evaluate the indications for metal artifact reduction sequence magnetic resonance imaging (MARS-MRI) and revision surgery. Methods Identification and recall of all patients with MoM hip replacements from 2001 were conducted by using theatre logs, patient records, clinical coding information, and consultant logbooks. Two senior arthroplasty consultants reviewed X-rays and patient records. Postal questionnaires were forwarded to patients, together with requests for general practitioners to complete cobalt and chromium blood tests. The two consultant-led review of MOM replacements was undertaken with further radiological investigations (X-rays, MARS-MRI) performed according to the 2017 guidance with support of consultant radiologists. Results Of 674 identified patients, 297 were available for review: 26 patients did not have MoM implants, 36 were untraceable, 59 refused follow-up, 87 moved out of area, 147 had died, and 22 already had revision. Of 297 patients, 126 were women and 171 were men; age range was 39 to 95 years (mean age, 69 years); 126 had resurfacing and 171 had MoM replacements. Twenty-six patients had elevated metal ions. Thirty-three patients underwent MARS-MRI: MARS-MRI results were positive in 17 and negative in 16. Of 17 patients with positive MARS-MRI, 10 patients were asymptomatic and seven were waiting revision. Conclusions Positive MARS-MRI can often occur in the absence of elevated metal ion levels; elevated blood metal ion levels do not mean MARS-MRI will be positive. All patients with MoM replacements were at risk. It is imperative to assess patients regularly for symptoms that may raise clinical suspicion and maintain a low threshold to performing MARS-MRI.
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Affiliation(s)
- Luke Hughes
- Department of Trauma and Orthopaedics, Blackburn Royal Infirmary, Blackburn, UK
| | - Kathryn Chamberlain
- Department of Trauma and Orthopaedics, Blackburn Royal Infirmary, Blackburn, UK
| | - Heather Robinson
- Department of Trauma and Orthopaedics, Blackburn Royal Infirmary, Blackburn, UK
| | - Andrew Sloan
- Department of Trauma and Orthopaedics, Blackburn Royal Infirmary, Blackburn, UK
| | - Qaisar Choudry
- Department of Trauma and Orthopaedics, Blackburn Royal Infirmary, Blackburn, UK
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Lehtovirta L, Reito A, Lainiala O, Parkkinen J, Hothi H, Henckel J, Hart A, Eskelinen A. Host-specific factors affect the pathogenesis of adverse reaction to metal debris. BMC Musculoskelet Disord 2019; 20:195. [PMID: 31054584 PMCID: PMC6499989 DOI: 10.1186/s12891-019-2578-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/16/2019] [Indexed: 02/08/2023] Open
Abstract
Background Adverse Reaction to Metal Debris (ARMD) is a major reason for revision surgeries in patients with metal-on-metal (MoM) hip replacements. Most failures are related to excessively wearing implant producing harmful metal debris (extrinsic factor). As ARMD may also occur in patients with low-wearing implants, it has been suggested that there are differences in host-specific intrinsic factors contributing to the development of ARMD. However, there are no studies that have directly assessed whether the development of ARMD is actually affected by these intrinsic factors. Methods We included all 29 patients (out of 33 patients) with sufficient data who had undergone bilateral revision of ASR MoM hips (58 hips) at our institution. Samples of the inflamed synovia and/or pseudotumour were obtained perioperatively and sent to histopathological analysis. Total wear volumes of the implants were assessed. Patients underwent MARS-MRI imaging of the hips preoperatively. Histological findings, imaging findings and total wear volumes between the hips of each patient were compared. Results The difference in wear volume between the hips was clinically and statistically significant (median difference 15.35 mm3, range 1 to 39 mm3, IQR 6 to 23 mm3) (p < 0.001). The median ratio of total wear volume between the hips was 2.0 (range 1.09 to 10.0, IQR 1.67 to 3.72). In majority of the histological features and in presence of pseudotumour, there were no differences between the left and right hip of each patient (p > 0.05 for all comparisons). These features included macrophage sheet thickness, perivascular lymphocyte cuff thickness, presence of plasma cells, presence of diffuse lymphocytic infiltration and presence of germinal centers. Conclusions Despite the significantly differing amounts of wear (extrinsic factor) seen between the sides, majority of the histological findings were similar in both hips and the presence of pseudotumour was symmetrical in most hips. As a direct consequence, it follows that there must be intrinsic factors which contribute to the symmetry of the findings, ie. the pathogenesis of ARMD, on individual level. This has been hypothesized in the literature but no studies have been conducted to confirm the hypothesis. Further, as the threshold of metal debris needed to develop ARMD appears to be largely variable based on the previous literature, it is likely that there are between-patient differences in these intrinsic factors, ie. the host response to metal debris is individual. Electronic supplementary material The online version of this article (10.1186/s12891-019-2578-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lari Lehtovirta
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland.,Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Tampere, Finland
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Langton DJ, Natu S, Harrington CF, Bowsher JG, Nargol AVF. Is the synovial fluid cobalt-to-chromium ratio related to the serum partitioning of metal debris following metal-on-metal hip arthroplasty? Bone Joint Res 2019; 8:146-155. [PMID: 30997040 PMCID: PMC6444018 DOI: 10.1302/2046-3758.83.bjr-2018-0049.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives We investigated the reliability of the cobalt-chromium (CoCr) synovial joint fluid ratio (JFR) in identifying the presence of a severe aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) response and/or suboptimal taper performance (SOTP) following metal-on-metal (MoM) hip arthroplasty. We then examined the possibility that the CoCr JFR may influence the serum partitioning of Co and Cr. Methods For part A, we included all revision surgeries carried out at our unit with the relevant data, including volumetric wear analysis, joint fluid (JF) Co and Cr concentrations, and ALVAL grade (n = 315). Receiver operating characteristic curves were constructed to assess the reliability of the CoCr JFR in identifying severe ALVAL and/or SOTP. For part B, we included only patients with unilateral prostheses who had given matched serum and whole blood samples for Co and Cr analysis (n = 155). Multiple regression was used to examine the influence of JF concentrations on the serum partitioning of Co and Cr in the blood. Results A CoCr JFR > 1 showed a specificity of 83% (77% to 88%) and sensitivity of 63% (55% to 70%) for the detection of severe ALVAL and/or SOTP. In patients with CoCr JFRs > 1, the median blood Cr to serum Cr ratio was 0.99, compared with 0.71 in patients with CoCr JFRs < 1 (p < 0.001). Regression analysis demonstrated that the blood Cr to serum Cr value was positively associated with the JF Co concentration (p = 0.011) and inversely related to the JF Cr concentration (p < 0.001). Conclusion Elevations in CoCr JFRs are associated with adverse biological (severe ALVAL) or tribocorrosive processes (SOTP). Comparison of serum Cr with blood Cr concentrations may be a useful additional clinical tool to help to identify these conditions.Cite this article: D. J. Langton, S. Natu, C. F. Harrington, J. G. Bowsher, A. V. F. Nargol. Is the synovial fluid cobalt-to-chromium ratio related to the serum partitioning of metal debris following metal-on-metal hip arthroplasty? Bone Joint Res 2019;8:146-155. DOI: 10.1302/2046-3758.83.BJR-2018-0049.R1.
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Affiliation(s)
- D J Langton
- Northern Retrieval Registry, The Biosphere, Newcastle Helix, Newcastle upon Tyne, UK
| | - S Natu
- University Hospital of North Tees, Stockton-on-Tees, UK
| | - C F Harrington
- Supra-Regional Assay Service (SAS), Trace Element Centre, Guildford, UK
| | - J G Bowsher
- Food and Drugs Administration, Silver Spring, Maryland, USA
| | - A V F Nargol
- University Hospital of North Tees, Stockton-on-Tees, UK
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Kovochich M, Finley BL, Novick R, Monnot AD, Donovan E, Unice KM, Fung ES, Fung D, Paustenbach DJ. Understanding outcomes and toxicological aspects of second generation metal-on-metal hip implants: a state-of-the-art review. Crit Rev Toxicol 2019; 48:853-901. [DOI: 10.1080/10408444.2018.1563048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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25
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Cr(VI)‐induced genotoxicity and cell cycle arrest in human osteoblast cell line MG‐63. J Appl Toxicol 2019; 39:1057-1065. [DOI: 10.1002/jat.3793] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/25/2019] [Accepted: 02/07/2019] [Indexed: 11/07/2022]
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Surgical Treatment of Intrapelvic Pseudotumour after Hip Resurfacing Arthroplasty: Case Report and Literature Review. Case Rep Orthop 2018; 2018:3808362. [PMID: 30498612 PMCID: PMC6222224 DOI: 10.1155/2018/3808362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/08/2018] [Accepted: 08/15/2018] [Indexed: 12/12/2022] Open
Abstract
Hip replacement is the surgery of the last century due to its impact on the quality of life. A pseudotumour is a rare complication of hip arthroplasty, and it is related to a metal-bearing surface. Pseudotumour is a challenging scenario for hip surgeons due to poor clinical outcomes. The patient consulted for hip pain and paresthesia in the left lower extremity, and analyses showed that the cause was a sizeable intrapelvic pseudotumour. A multidisciplinary team surgery was planned. At first, an infraumbilical approach was made to resect the intrapelvic-retroperitoneum portion of the pseudotumour. Then, a posterolateral hip approach was performed, to resect the remaining portion of the pseudotumour and revision arthroplasty. At five years of follow-up, there are no clinical or imaging signs of recurrence of the pseudotumour. Treatment evidence is limited to a series of cases and expert opinions; we encourage complete resection and revision arthroplasty.
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Mercuri LG, Miloro M, Skipor AK, Bijukumar D, Sukotjo C, Mathew MT. Serum Metal Levels in Maxillofacial Reconstructive Surgery Patients: A Pilot Study. J Oral Maxillofac Surg 2018; 76:2074-2080. [DOI: 10.1016/j.joms.2018.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
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Sensitivity and Specificity of Metal Ion Level in Predicting Adverse Local Tissue Reactions Due to Head-Neck Taper Corrosion in Primary Metal-on-Polyethylene Total Hip Arthroplasty. J Arthroplasty 2018; 33:3025-3029. [PMID: 29748069 DOI: 10.1016/j.arth.2018.04.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/06/2018] [Accepted: 04/05/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is increasing concern regarding the occurrence of adverse local tissue reactions (ALTRs) in metal-on-polyethylene (MoP) total hip arthroplasty (THA) patients due to mechanically assisted crevice corrosion at the head-neck modular taper junction. The utility of metal ion levels in evaluating MoP patients with head-neck taper has not been fully characterized. This study aimed to investigate the sensitivity and specificity of serum metal ions as a predictor of ALTR in MoP THA patients. METHODS A total of 62 MoP THA patients in 2 cohorts were investigated: (1) ALTR on metal artifact reduction sequence magnetic resonance imaging (n = 43) and (2) without ALTR on metal artifact reduction sequence magnetic resonance imaging (n = 19). Receiver-operating characteristic curve was constructed to determine the sensitivity and specificity using different metal ion thresholds and the optimal metal ion cutoff values. RESULTS The presence of ALTR was associated with significantly higher cobalt (8.9 ng/mL vs 0.3 ng/mL, P < .001), chromium (2.26 ng/mL vs 0.21 ng/mL, P < .001), and Co/Cr ratio (5.9 vs 2.0, P < .001). The sensitivity and specificity for cobalt (1 ng/mL) was 95% and 94% and for Co/Cr ratio (2) was 83% and 72%, respectively. CONCLUSIONS Although metal ion levels alone should not be relied on as the sole parameter to determine revision surgery, serum cobalt level of >1 ng/mL (1 ppb) and Co/Cr ratio >2 thresholds provide evidence-based practical information for surgeons when interpreting metal ion levels in MoP THA patients for clinically relevant head-neck taper corrosion.
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Gascoyne TC, Turgeon TR, Burnell CD. Retrieval Analysis of Large-Head Modular Metal-on-Metal Hip Replacements of a Single Design. J Arthroplasty 2018; 33:1945-1952. [PMID: 29402714 DOI: 10.1016/j.arth.2017.12.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/23/2017] [Accepted: 12/31/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There are limited publications examining modular metal-on-metal (MoM) total hip implants in which a comprehensive analysis of retrieved components is performed. This study examines 24 retrieved modular MoM implants from a single manufacturer and compares retrieval analytics; bearing surface damage, wear, and modular taper corrosion against patient, surgical and implant characteristics to elucidate significant associations. METHODS Clinical, patient, and surgical data were collected including age, body mass index, blood metal ion levels, and cup inclination. Damage assessment was performed visually in addition to surface profilometry. Acetabular liners and femoral heads were measured for volumetric wear. Femoral head taper bores were similarly measured for material removal due to corrosion and fretting. RESULTS Patients with MoM-related reasons for revision showed significantly higher levels of blood metal ion levels. Bearing wear was strongly associated with blood metal ion levels and was significantly increased in cups placed more vertically. Younger patients tended to have higher body mass indices as well as poorer cup placement. CONCLUSION This work details a broad range of analyses on a series of modular MoM total hip implants from a single manufacturer of which there are few published studies. Acetabular cup inclination angle was deemed a primary cause of revision surgery through increased MoM wear, high metal ion levels in the blood, and subsequent adverse local tissue reactions. Heavy patients can increase the surgical difficulty which was shown to be related to poor cup placement in this cohort.
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Affiliation(s)
| | - Thomas R Turgeon
- Concordia Joint Replacement Group, Winnipeg, Manitoba, Canada; Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Colin D Burnell
- Concordia Joint Replacement Group, Winnipeg, Manitoba, Canada; Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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Bouveau V, Haen TX, Poupon J, Nich C. Outcomes after revision of metal on metal hip resurfacing to total arthroplasty using the direct anterior approach. INTERNATIONAL ORTHOPAEDICS 2018. [PMID: 29520467 DOI: 10.1007/s00264-018-3858-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Function after revision total hip arthroplasty (THA) in failed metal-on-metal (MoM) hip resurfacing arthroplasty (HRA) is variable, but post-operative complication rates are reportedly high. We hypothesized HRA conversion to THA using the direct anterior approach (DAA) would be associated with optimal outcome. METHODS Seventeen MoM-HRAs in 15 patients (seven males, eight females) were revised through the DAA. The mean age was 45 years (28-59 yrs). The most common indications for revision were aseptic loosening of the acetabular component or of the femoral component and femoral neck fracture. In 16 hips, a conversion to a ceramic-on-ceramic (CoC) (13 hips) or to a metal-on polyethylene (MOP) (2), or to a large-head MoM (1) THA was done. An isolated femoral revision was done in one hip. RESULTS After 6.7 ± 3 years, no hip had required a re-revision. The Postel-Merle d'Aubigne (PMA) functional score improved from 9 (4-14) to 16 (12-18) (p < 0.001). An intra-operative fracture of the greater trochanter (one hip) and dysesthesia of the lateral femoral cutaneous nerve (four hips) were reported. Mean serum chromium concentration decreased from 33.2 μg/L (11.8-62 μg/L) pre-operatively to 5.8 μg/L (0.4-35.5 μg/L) post-operatively (p < 0.001), and mean serum cobalt concentration decreased from 35.8 μg/L (6.3-85.5 μg/L) to 4.7 μg/L (0.26-25.7 μg/L) (p = 0.003). CONCLUSION Revision of failed MoM-HRA using the DAA resulted in an acceptable clinical outcome, no specific complication and no further surgery. A consistent decline in serum ion levels may be expected following HRA conversion to THA.
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Affiliation(s)
- Victoire Bouveau
- Department of Traumatology and Orthopaedic Surgery, Raymond Poincare Hospital, Versailles Saint Quentin en Yvelines University, Assistance Publique - Hôpitaux de Paris, 104 Boulevard Raymond Poincare, 92380, Garches, France
| | - Thomas-Xavier Haen
- Department of Traumatology and Orthopaedic Surgery, Raymond Poincare Hospital, Versailles Saint Quentin en Yvelines University, Assistance Publique - Hôpitaux de Paris, 104 Boulevard Raymond Poincare, 92380, Garches, France
| | - Joel Poupon
- Department of Biological Toxicology, Lariboisiere Hospital, Paris 7 Diderot University, Assistance Publique Hôpitaux de Paris, 2 rue Ambroise Pare, 75475 Paris Cedex 10, Paris, France
| | - Christophe Nich
- Department of Traumatology and Orthopaedic Surgery, Raymond Poincare Hospital, Versailles Saint Quentin en Yvelines University, Assistance Publique - Hôpitaux de Paris, 104 Boulevard Raymond Poincare, 92380, Garches, France.
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Park SH, Lu Z, Hastings RS, Campbell PA, Ebramzadeh E. Five Hundred Fifty-five Retrieved Metal-on-metal Hip Replacements of a Single Design Show a Wide Range of Wear, Surface Features, and Histopathologic Reactions. Clin Orthop Relat Res 2018; 476:261-278. [PMID: 29529655 PMCID: PMC6259711 DOI: 10.1007/s11999.0000000000000044] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In 2010, a widely used metal-on-metal hip implant design was voluntarily recalled by the manufacturer because of higher than anticipated failure rates at 5 years. Although there was a large published range of revision rates, numerous studies had reported a higher risk of revision for excessive wear and associated adverse tissue reactions when compared with other metal-on-metal total hips. The reasons for this were suggested by some to be related to cup design features. QUESTIONS/PURPOSES From retrievals of ASR metal-on-metal implants and tissue samples obtained at revision surgery, we asked the following questions: (1) What were the common and uncommon surface features? (2) What were the common and uncommon linear and volumetric wear characteristics? (3) Were there common taper corrosion characteristics? (4) What aseptic lymphocytic vasculitis-associated lesion (ALVAL) features were present in the tissues? METHODS Five hundred fifty-five ASRs, including 23 resurfacings, were studied at one academic research center. Features of wear (eg, light and moderate scratching), damage (eg, deposits, gouges), and bone attachment on the porous coating were semiquantitatively ranked from 0 (none) to 3 (> 75%) based on the amount of a feature in each region of interest by the same experienced observer throughout the study. Visible features of head taper corrosion were ranked (Goldberg score) from 1 (none) to 4 (severe) by the same observer using a previously published scoring method. An experienced tribologist measured component wear depth using a coordinate measuring machine and quantified wear volume using previously validated methods. All available tissues were sampled and examined for features of ALVAL and scored from 0 to 10 by a single observer using a method they previously developed and published. A score from 0 to 4 is considered low, 5 to 8 is considered moderate, and 9 or 10 is considered high with regard to the risk of metal hypersensitivity features in the tissues. RESULTS The most common bearing surface features were light and moderate scratches and removal or postremoval damage. Discoloration and deposits were commonly observed on femoral heads (55% [305 of 553]) and less commonly on cups (30% [165 of 546]). There was no evidence of impingement or dislocation damage. There was typically a small amount of bone attachment in at least one of eight designated regions of interest (84% [460 of 546]); extensive or no bone attachment was uncommon. Edge wear was highly prevalent. The maximum wear of 469 cups (88%) occurred near the edge, whereas the maximum wear of 508 femoral heads (94%) occurred between the pole and 45° from the pole. The median combined head-cup wear volume was 14 mm (range, 1-636 mm). One hundred sixty-nine pairs (32%) had a combined wear volume of < 10 mm, 42 pairs (8%) had volumetric wear of > 100 mm, and 319 pairs (60%) had wear volume between 10 and 100 mm³. Seventy-four percent of tapers (390 of 530) received a Goldberg score of 4, 22% (116 of 530) a score of 3, < 5% (24 of 530) a score of 2, and none received a score of 1. The most frequent ALVAL score was 5 out of 10 (35 of 144 hips [24%]) and ranged from 2 (one hip) to 10 (nine hips); 92 of 144 (64%) had a moderate score, 17 of 144 (12%) had a high score, and 35 (24%) had a low score. CONCLUSIONS Although edge wear was prevalent, in most cases, this was not associated with high wear. The increased diameter and decreased coverage angle of the ASR design may have resulted in the observed high incidence of edge wear while perhaps decreasing the risk for impingement and dislocation. CLINICAL RELEVANCE The role of bearing wear in the revisions of metal-on-metal implants is controversial, because it is known that there is a large range of in vivo wear rates even within the same implant type and that patient variability affects local tissue responses to wear debris. The observations from our study of 555 retrieved ASR implant sets indicate that there was a wide range of wear including a subset with very high wear. The results suggested that the failure of the ASR and ASR XL was multifactorial, and the failure of different subgroups such as those with low wear may be the result of mechanisms other than reaction to wear debris.
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Affiliation(s)
- Sang-Hyun Park
- S.-H. Park, Z. Lu, P. A. Campbell, E. Ebramzadeh, The J. Vernon Luck, Sr, MD Orthopaedic Research Center, Orthopaedic Institute for Children and UCLA Department of Orthopaedic Surgery, Los Angeles, CA, USA R. S. Hastings, DePuy, Inc, Warsaw, IN, USA
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Matharu GS, Judge A, Eskelinen A, Murray DW, Pandit HG. What is appropriate surveillance for metal-on-metal hip arthroplasty patients? Acta Orthop 2018; 89:29-39. [PMID: 29105547 PMCID: PMC5810829 DOI: 10.1080/17453674.2017.1398011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The unexpected high revision rates of large-diameter (femoral head sizes of 36 mm or greater) metal-on-metal hip arthroplasties (MoMHAs) have led to worldwide regulatory authorities recommending regular surveillance, even for asymptomatic individuals. However, these recommendations are not evidence-based and are very costly. The rapidly evolving evidence base requires an update regarding the investigation and management of MoMHA patients. This article is the first of 2 (the second article in this series will consider the threshold for performing revision, and the outcomes following ARMD revision surgery: Matharu et al., Revision surgery of metal-on-metal hip arthroplasties for adverse reactions to metal debris: A clinical update. Acta Orthop 2018; in press), and considers the various investigative modalities used during surveillance, with specific focus on blood metal ion sampling and cross-sectional imaging. No single investigation can universally be used during MoMHA patient surveillance. Recent studies have now provided important information on interpreting blood metal ions (effective in identifying patients at low risk of problems), clarifying the roles of cross-sectional imaging (reserve combined ultrasound and MARS-MRI for complex cases), and providing parameters to safely exclude many asymptomatic patients from regular surveillance. This information will be useful when designing future surveillance protocols for MoMHA patients.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK;,Correspondence:
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | | | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
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Fung ES, Monnot A, Kovochich M, Unice KM, Tvermoes BE, Galbraith D, Finley BL, Paustenbach DJ. Characteristics of Cobalt-Related Cardiomyopathy in Metal Hip Implant Patients: An Evaluation of 15 Published Reports. Cardiovasc Toxicol 2017; 18:206-220. [PMID: 29188590 DOI: 10.1007/s12012-017-9433-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Over 300,000 hip replacements occurred in the USA in 2010, and the frequency is likely increasing annually. Blood Cobalt (Co) concentrations in patients with well-functioning cobalt-chromium (Co-Cr) hip implants are usually elevated above background concentrations relative to the general population. Excessive Co exposure, in rare cases, can result in cardiomyopathy. The purpose of this review was to identify cases of cardiomyopathy in metal-containing hip implant patients and to evaluate the possible cause of each patient's cardiomyopathy. We evaluated 15 cases published between 2009 and 2016, and, based on a review of the preexisting risk factors, blood Co concentrations, and histopathological information published for each patient, they were stratified into one of four categories regarding the association between Co exposure and the development of cardiomyopathy: (1) Co was causal (five cases); (2) Co was contributory (two cases); (3) Co was possibly contributory (six cases); and (4) Co was non-causal (two cases). In all 15 cases, blood Co concentrations (14-6521 μg/L) were elevated beyond levels associated with the majority of metal-containing implant patients (0.1-10 μg/L), and, in many cases, there was evidence of a malfunctioning implant. The data indicate that individuals with well-functioning implants, even those with preexisting risk factors, are at no risk of developing cardiac effects. We conclude that blood Co measurements are informative, but should be interpreted with caution, and in context of other factors evaluated in this analysis. The mere presence of elevated Co is not sufficient to indicate causation for a patient's cardiomyopathy.
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Affiliation(s)
- Ernest S Fung
- Cardno ChemRisk, 65 Enterprise, Suite 150, Aliso Viejo, CA, 92656, USA
| | - Andrew Monnot
- Cardno ChemRisk, 101 2nd St. Suite 700, San Francisco, CA, 94105, USA
| | - Michael Kovochich
- Cardno ChemRisk, 65 Enterprise, Suite 150, Aliso Viejo, CA, 92656, USA.
| | - Kenneth M Unice
- Cardno ChemRisk, 20 Stanwix St. Suite 505, Pittsburgh, PA, 15222, USA
| | - Brooke E Tvermoes
- Cardno ChemRisk, 4940 Pearl East Circle Suite 100, Boulder, CO, 80301, USA.,IBM, Boulder, CO, USA
| | - David Galbraith
- Cardno ChemRisk, 101 2nd St. Suite 700, San Francisco, CA, 94105, USA
| | - Brent L Finley
- Cardno ChemRisk, 231 Front St. Suite 212, Brooklyn, NY, 11201, USA
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Fang X, Liu Y, Jimenez L, Duan Y, Adkins GB, Qiao L, Liu B, Zhong W. Rapid Enrichment and Sensitive Detection of Multiple Metal Ions Enabled by Macroporous Graphene Foam. Anal Chem 2017; 89:11758-11764. [PMID: 29034677 PMCID: PMC5687914 DOI: 10.1021/acs.analchem.7b03336] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Nanomaterials have shown great promise in advancing biomedical and environmental analysis because of the unique properties originated from their ultrafine dimensions. In general, nanomaterials are separately applied to either enhance detection by producing strong signals upon target recognition or to specifically extract analytes taking advantage of their high specific surface area. Herein, we report a dual-functional nanomaterial-based platform that can simultaneously enrich and enable sensitive detection of multiple metal ions. The macroporous graphene foam (GF) we prepared displays abundant phosphate groups on the surface and can extract divalent metal ions via metal-phosphate coordination. The enriched metal ions then activate the metal-responsive DNAzymes and produce the fluorescently labeled single-stranded DNAs that are adsorbed and quenched by the GF. The resultant fluorescence reduction can be used for metal quantitation. The present work demonstrated duplexed detection of Pb2+ and Cu2+ using the Pb- and Cu-responsive DNAzymes, achieving a low detection limit of 50 pM and 0.6 nM, respectively. Successful quantification of Pb2+ and Cu2+ in human serum and river water were achieved with high metal recovery. Since the phosphate-decorated GF can enrich diverse types of divalent metal cations, this dual-functional GF-DNAzyme platform can serve as a simple and cost-effective tool for rapid and accurate metal quantification in determination of human metal exposure and inspection of environmental contamination.
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Affiliation(s)
- Xiaoni Fang
- Department of Chemistry, University of California, Riverside, 92521 CA
| | - Yang Liu
- Department of Chemistry, University of California, Riverside, 92521 CA
| | - Luis Jimenez
- Department of Chemistry, University of California, Riverside, 92521 CA
| | - Yaokai Duan
- Department of Chemistry, University of California, Riverside, 92521 CA
| | - Gary Brent Adkins
- Department of Chemistry, University of California, Riverside, 92521 CA
| | - Liang Qiao
- Department of Chemistry, Institute of Biomedical Sciences and State Key Lab of Molecular Engineering of Polymers, Shanghai Stomatological Hospital, Fudan University, Shanghai 200433, China
| | - Baohong Liu
- Department of Chemistry, Institute of Biomedical Sciences and State Key Lab of Molecular Engineering of Polymers, Shanghai Stomatological Hospital, Fudan University, Shanghai 200433, China
| | - Wenwan Zhong
- Department of Chemistry, University of California, Riverside, 92521 CA
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Bone MC, Naylor A. Failure of an ACCIS metal-on-metal hip resurfacing prosthesis: A case report. Proc Inst Mech Eng H 2017; 231:1188-1194. [PMID: 29105561 DOI: 10.1177/0954411917737457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The introduction of coatings on joint replacements was intended to reduce wear volumes, prevent corrosion and reduce metal ion release. However, retrieval analysis to confirm their in vivo performance has been limited. The aim of study was to examine the coating on a retrieved hip prosthesis to determine whether substantial damage or wear had occurred. A single advanced ceramic-coated implant systems titanium niobium nitride-coated hip resurfacing prosthesis was retrieved for examination. Wear volumes and surface roughness were measured to quantify the damage to the articulating surfaces. The coating had been completely removed from substantial parts of both the femoral head and the acetabular cup, corresponding to areas of wear as measured by a coordinate measuring machine. The total wear rate (61 mm3/year) was high and corresponded with the high metal ion levels recorded pre-operatively (83 ppb chromium and 110 ppb cobalt). Roughness data indicated that the coating has a lower roughness than the substrate and substantially lower than the boundary between the coating and the substrate. The wear rate is very high and it is likely that damage to the coating resulted in accelerated wear of the prosthesis. No sudden change between the boundary of the substrate and the coating was observed that would indicate delamination or failure of the coating substrate interface layer. While coatings may offer some theoretical benefits, they may also result in catastrophic failure of the prosthesis.
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Affiliation(s)
- Martin C Bone
- 1 Faculty of Engineering, University of New South Wales, Sydney, Australia
| | - Andrew Naylor
- 2 School of Engineering, Newcastle University, Newcastle upon Tyne, UK
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Pernaa K, Saltychev M, Mäkelä K. Relationship between Pelvic Incidence Angle and Blood Concentration of Chromium and Cobalt Ions after Metal-on-Metal Hip Replacement: A Brief Report. Scand J Surg 2017; 107:91-94. [PMID: 28931352 DOI: 10.1177/1457496917731182] [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: 11/16/2022]
Abstract
BACKGROUND AND AIMS The wear of metal-on-metal hip implants may increase chromium or cobalt ion blood level. This phenomenon may depend among other things on the particularity of spinopelvic anatomy. The effect of pelvic incidence angle on the wear of metal-on-metal hip implants is not known. The objective of the study was to investigate whether such effect does exist. MATERIAL AND METHODS The pelvic incidence and inclination of acetabular component angles of 89 patients after unilateral metal-on-metal hip replacement were compared with blood level of chromium and cobalt ions using Pearson correlation coefficient. RESULTS No significant correlations between pelvic incidence angle and the metal ion blood levels were observed. The correlation coefficients varied from -0.02 to 0.2 and all p values were >0.05. CONCLUSION No evidence was found on the effect of pelvic incidence angle on metal wear after metal-on-metal hip replacement when measured by the blood levels of chromium and cobalt ions. It is reasonable to assume that other factors than pelvic tilt may affect the rate of implant wear.
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Affiliation(s)
- K Pernaa
- 1 Department of Orthopedics and Traumatology, Turku University Hospital, Turku, Finland.,2 University of Turku, Turku, Finland
| | - M Saltychev
- 2 University of Turku, Turku, Finland.,3 Department of Physical and Rehabilitation Medicine, Turku University Hospital, Turku, Finland
| | - K Mäkelä
- 1 Department of Orthopedics and Traumatology, Turku University Hospital, Turku, Finland.,2 University of Turku, Turku, Finland
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Matharu GS, Berryman F, Judge A, Reito A, McConnell J, Lainiala O, Young S, Eskelinen A, Pandit HG, Murray DW. Blood Metal Ion Thresholds to Identify Patients with Metal-on-Metal Hip Implants at Risk of Adverse Reactions to Metal Debris: An External Multicenter Validation Study of Birmingham Hip Resurfacing and Corail-Pinnacle Implants. J Bone Joint Surg Am 2017; 99:1532-1539. [PMID: 28926382 PMCID: PMC5805279 DOI: 10.2106/jbjs.16.01568] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The authors of recent studies have reported newly devised implant-specific blood metal ion thresholds to predict adverse reactions to metal debris (ARMD) in patients who have undergone unilateral or bilateral metal-on-metal (MoM) hip arthroplasty. These thresholds were most effective for identifying patients at low risk of ARMD. We investigated whether these newly devised blood metal ion thresholds could effectively identify patients at risk of ARMD after MoM hip arthroplasty in an external cohort of patients. METHODS We performed a validation study involving 803 MoM hip arthroplasties (323 unilateral Birmingham Hip Resurfacing [BHR], 93 bilateral BHR, and 294 unilateral Corail-Pinnacle implants) performed in 710 patients at 3 European centers. All patients underwent whole-blood metal ion sampling, and were divided into 2 groups: those with ARMD (leading to revision or identified on imaging; n = 75) and those without ARMD (n = 635). Previously devised implant-specific blood metal ion thresholds (2.15 μg/L of cobalt for unilateral BHR; 5.5 μg/L for the maximum of either cobalt or chromium for bilateral BHR; and 3.57 μg/L of cobalt for unilateral Corail-Pinnacle implants) were applied to the validation cohort, and receiver operating characteristic curve analysis was used to establish the discriminatory characteristics of each threshold. RESULTS The area under the curve, sensitivity, specificity, and positive and negative predictive values for the ability of each implant-specific threshold to distinguish between patients with and without ARMD were, respectively, 89.4% (95% confidence interval [CI] = 82.8% to 96.0%), 78.9%, 86.7%, 44.1%, and 96.9% for unilateral BHR; 89.2% (CI = 81.3% to 97.1%), 70.6%, 86.8%, 54.5%, and 93.0% for bilateral BHR; and 76.9% (CI = 63.9% to 90.0%), 65.0%, 85.4%, 24.5%, and 97.1% for unilateral Corail-Pinnacle implants. Using the implant-specific thresholds, we missed 20 patients with ARMD (2.8% of the patients in this series). We missed more patients with ARMD when we used the fixed thresholds proposed by regulatory authorities: 35 (4.9%) when we used the U.K. threshold of 7 μg/L for both cobalt and chromium (p = 0.0003), 21 (3.0%) when we used the U.S. threshold of 3 μg/L for both cobalt and chromium (p = 1.0), and 46 (6.5%) when we used the U.S. threshold of 10 μg/L for both cobalt and chromium (p < 0.0001). CONCLUSIONS This external multicenter validation study confirmed that patients with blood metal ion levels below new implant-specific thresholds have a low risk of ARMD after MoM hip arthroplasty. Using these implant-specific thresholds, we missed fewer patients with ARMD compared with when the thresholds currently proposed by regulatory authorities were used. We therefore recommend using implant-specific blood metal ion thresholds when managing patients who have undergone MoM hip arthroplasty. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gulraj S. Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Fiona Berryman
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, United Kingdom
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | | | - Hemant G. Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Chapel Allerton Hospital, Leeds, United Kingdom
| | - David W. Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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Carlson BC, Bryan AJ, Carrillo-Villamizar NT, Sierra RJ. The Utility of Metal Ion Trends in Predicting Revision in Metal-on-Metal Total Hip Arthroplasty. J Arthroplasty 2017; 32:S214-S219. [PMID: 28320566 DOI: 10.1016/j.arth.2017.02.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/03/2017] [Accepted: 02/11/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is a paucity of data examining metal ion levels over time. METHODS We retrospectively reviewed 59 patients (69 hips) with an articular surface replacement total hip arthroplasty. We reviewed prerevision cobalt and chromium concentrations over time. RESULTS Seventy-one percent of patients who were revised and had multiple ion measurements (12/17) demonstrated increasing cobalt ion levels or elevated ion levels over time. There was a trend toward an elevated risk of revision for increasing cobalt and chromium levels starting at 12 and 4 ppb, respectively; this was significant for chromium levels above 7 ppb (hazard ratio 22.35, P = .001). Similarly, there was a trend toward an elevated risk of pseudotumor formation for increasing cobalt and chromium levels starting at 5 and 2.5 ppb, respectively; this was significant for cobalt levels above 7 ppb (hazard ratio 6.88, P = .027). CONCLUSION In this paper, cobalt and chromium levels levels above 5 and 2.5 ppb started to demonstrate an increased risk of ARMD, and should be considered as a lower cutoff for discussion with patients about the potential for future revision.
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Affiliation(s)
- Bayard C Carlson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew J Bryan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Leyssens L, Vinck B, Van Der Straeten C, Wuyts F, Maes L. Cobalt toxicity in humans-A review of the potential sources and systemic health effects. Toxicology 2017; 387:43-56. [PMID: 28572025 DOI: 10.1016/j.tox.2017.05.015] [Citation(s) in RCA: 419] [Impact Index Per Article: 59.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/17/2017] [Accepted: 05/24/2017] [Indexed: 12/21/2022]
Abstract
Cobalt (Co) and its compounds are widely distributed in nature and are part of numerous anthropogenic activities. Although cobalt has a biologically necessary role as metal constituent of vitamin B12, excessive exposure has been shown to induce various adverse health effects. This review provides an extended overview of the possible Co sources and related intake routes, the detection and quantification methods for Co intake and the interpretation thereof, and the reported health effects. The Co sources were allocated to four exposure settings: occupational, environmental, dietary and medical exposure. Oral intake of Co supplements and internal exposure through metal-on-metal (MoM) hip implants deliver the highest systemic Co concentrations. The systemic health effects are characterized by a complex clinical syndrome, mainly including neurological (e.g. hearing and visual impairment), cardiovascular and endocrine deficits. Recently, a biokinetic model has been proposed to characterize the dose-response relationship and effects of chronic exposure. According to the model, health effects are unlikely to occur at blood Co concentrations under 300μg/l (100μg/l respecting a safety factor of 3) in healthy individuals, hematological and endocrine dysfunctions are the primary health endpoints, and chronic exposure to acceptable doses is not expected to pose considerable health hazards. However, toxic reactions at lower doses have been described in several cases of malfunctioning MoM hip implants, which may be explained by certain underlying pathologies that increase the individual susceptibility for Co-induced systemic toxicity. This may be associated with a decrease in Co bound to serum proteins and an increase in free ionic Co2+. As the latter is believed to be the primary toxic form, monitoring of the free fraction of Co2+ might be advisable for future risk assessment. Furthermore, future research should focus on longitudinal studies in the clinical setting of MoM hip implant patients to further elucidate the dose-response discrepancies.
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Affiliation(s)
- Laura Leyssens
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Bart Vinck
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium; Faculty of Humanities, University of Pretoria (South Africa), Department of Speech-Language Pathology and Audiology, Aula Theatre,University Road, Pretoria, 0001, South Africa.
| | - Catherine Van Der Straeten
- Faculty of Medicine, Imperial College London, Department of Surgery & Cancer, Musculoskeletal Sciences and Technology, Imperial College London, Charing Cross Campus,7L21 Lab Block, London SW7 2AZ, UK; Faculty of Medicine and Health Sciences, University of Ghent (Belgium), De Pintelaan 185, 9000 Ghent, Belgium.
| | - Floris Wuyts
- Antwerp University Research center for Equilibrium and Aerospace (AUREA), Department of Otorhinolaryngology, University Hospital Antwerp, Campus Groenenborger, Groenenborgerlaan 171, 2020 Antwerp, Belgium; Department of Biomedical Physics, University of Antwerp (Belgium), Campus Groenenborger, Groenenborgerlaan 171, 2020 Antwerp, Belgium.
| | - Leen Maes
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium; Clinical audiology department, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium.
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Contact patch to rim distance: the quintessential tool for metal-on-metal bearing in vivo performance analysis - a review. Hip Int 2017; 27:220-225. [PMID: 28478641 DOI: 10.5301/hipint.5000511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2017] [Indexed: 02/04/2023]
Abstract
With metal-on-metal (MoM) bearings, fluid film lubrication is disrupted when the contact patch area between the femoral head and the cup is close to the edge of the acetabular component, making the calculation of the contact patch to rim (CPR) distance a key variable in the study of the performance of MoM bearings. A few research centers have used models of varying complexity to calculate the CPR distance and determine its relationship with assessments of component wear. In this review, we aimed to summarise the current knowledge related to the application of CPR distance calculations in the study of in vivo performance of MoM bearings. Our systematic search of the US National Library of Medicine yielded 9 relevant publications in which 3 different models were used for the computation of the CPR distance. The 3 models show different levels of complexity and their use is mainly dependent upon the size of the subject sample and the nature of the data collected as a dependent variable. The studies reviewed consistently showed a strong inverse correlation between CPR distance and wear or metal ion levels suggesting that any study aiming to determine the risk factors for MoM hip devices needs to include an assessment of CPR distance. Cup anteversion can be measured reliably with various tools and should not be an obstacle to the use of this essential variable that is CPR distance.
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Nodzo SR, Esposito CI, Potter HG, Ranawat CS, Wright TM, Padgett DE. MRI, Retrieval Analysis, and Histologic Evaluation of Adverse Local Tissue Reaction in Metal-on-Polyethylene Total Hip Arthroplasty. J Arthroplasty 2017; 32:1647-1653. [PMID: 28087160 DOI: 10.1016/j.arth.2016.11.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 11/15/2016] [Accepted: 11/28/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The severity and location of adverse local tissue reaction (ALTR) seen in metal-on-polyethylene total hip arthroplasty (THA) is not well described. METHODS We retrospectively reviewed the records of patients who underwent a revision THA using our biomechanics database. We included all patients who underwent revision surgery for the diagnosis of ALTR with THA implants that had modularity solely at the head-neck junction and excluded patients with implant modularity at sites other than the head-neck junction. Magnetic resonance imaging (MRI) was evaluated by a fellowship-trained radiologist who specializes in evaluating metal artifact reducing MRI sequences to quantify the ALTR lesions. Histology was evaluated for findings of ALTR using the Campbell score. RESULTS We identified 11 patients in the database. Eight patients had an MRI ALTR grade of severe and 7 did based on the histology score. The mean synovial volume was 218,658 mm3 (range 23,461-451,435 mm3) with a mean maximal synovial thickness of 15.3 mm (range 3-34.3 mm). A disruptive infiltration of the abductors due to pseudocapsule invasion was seen in 67% of the patients with 3 not having abductor involvement. Mean preoperative cobalt and chromium levels were 5.4 ppb (range 1-12.3 ppb) and 1.1 ppb (range 0.6-2.4 ppb), respectively. CONCLUSION Patients with ALTR from head-neck junction corrosion in metal-on-polyethylene THA may present with large pseudotumors that have previously been under appreciated. Mean preoperative serum cobalt and chromium ion levels remained relatively low, and MRI was an effective way to characterize the size and location of these lesions.
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Affiliation(s)
- Scott R Nodzo
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York
| | | | - Hollis G Potter
- Department of Radiology, Hospital for Special Surgery, New York, New York
| | | | - Timothy M Wright
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Douglas E Padgett
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York
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Barlow BT, Ortiz PA, Boles JW, Lee YY, Padgett DE, Westrich GH. What Are Normal Metal Ion Levels After Total Hip Arthroplasty? A Serologic Analysis of Four Bearing Surfaces. J Arthroplasty 2017; 32:1535-1542. [PMID: 28190644 DOI: 10.1016/j.arth.2016.11.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/27/2016] [Accepted: 11/14/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The recent experiences with adverse local tissue reactions have highlighted the need to establish what are normal serum levels of cobalt (Co), chromium (Cr), and titanium (Ti) after hip arthroplasty. METHODS Serum Co, Cr, and Ti levels were measured in 80 nonconsecutive patients with well-functioning unilateral total hip arthroplasty and compared among 4 bearing surfaces: ceramic-on-ceramic (CoC); ceramic-on-polyethylene (CoP); metal-on-polyethylene (MoP), and dual mobility (DM). The preoperative and most recent University of California, Los Angeles (UCLA) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were compared among the different bearing surfaces. RESULTS No significant difference was found among serum Co and Cr levels between the 4 bearing surface groups (P = .0609 and P = .1577). Secondary analysis comparing metal and ceramic femoral heads demonstrated that the metal group (MoP, modular dual mobility (Stryker Orthopedics, Mahwah, NJ) [metal]) had significant higher serum Co levels compared with the ceramic group (CoC, CoP, MDM [ceramic]) (1.05 mg/L ± 1.25 vs 0.59 mg/L ± 0.24; P = .0411). Spearman coefficient identified no correlation between metal ion levels and patient-reported outcome scores. CONCLUSION No serum metal ion level differences were found among well-functioning total hip arthroplasty with modern bearing couples. Significantly higher serum Co levels were seen when comparing metal vs ceramic femoral heads in this study and warrants further investigation. Metal ion levels did not correlate with patient-reported outcome measures.
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Affiliation(s)
- Brian T Barlow
- Division of Adult Reconstruction and Joint Replacement Surgery, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Philippe A Ortiz
- Division of Adult Reconstruction and Joint Replacement Surgery, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - John W Boles
- Division of Adult Reconstruction and Joint Replacement Surgery, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Yuo-Yu Lee
- Epidemiology and Biostatistics Core, Hospital for Special Surgery, New York, New York
| | - Douglas E Padgett
- Division of Adult Reconstruction and Joint Replacement Surgery, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Geoffrey H Westrich
- Division of Adult Reconstruction and Joint Replacement Surgery, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
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Langton DJ. Response to Letter to the Editor on "Factors Associated With Trunnionosis in the Metal-on-Metal Pinnacle Hip". J Arthroplasty 2017; 32:1045-1046. [PMID: 27894671 DOI: 10.1016/j.arth.2016.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 10/19/2016] [Indexed: 02/01/2023] Open
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Langton D, Ahmed I, Avery P, Bone M, Cooke N, Deehan D, Duffy P, Foguet P, Green S, Holland J, Jafri A, Longstaff L, Lord J, Loughead J, Meek RMD, Murray H, Nanu A, Nargol AVF, Scholes SC, Sidaginamale RP, Waller S, Joyce T. Investigation of Taper Failure in a Contemporary Metal-on-Metal Hip Arthroplasty System Through Examination of Unused and Explanted Prostheses. J Bone Joint Surg Am 2017; 99:427-436. [PMID: 28244914 DOI: 10.2106/jbjs.15.00917] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Large-diameter (≥36-mm) metal-on-metal (MoM) total hip replacements have been shown to fail at an unacceptably high rate. Globally, the DePuy Pinnacle prosthesis was the most widely used device of this type. There is evidence to suggest that one of the main reasons for the poor clinical performance of large-diameter MoM prostheses is the metal debris released from the head-stem taper junction-i.e., taper junction failure. The aim of this study was to investigate variation in the as-manufactured finish of the female taper surface and to determine its influence on material loss. We hypothesized that rougher surfaces with higher relative material peaks would be significantly associated with greater taper wear rates. METHODS We analyzed 93 Articul/eze femoral head tapers with a 36-mm bearing diameter that had been used in combination with a Corail titanium uncemented stem. The influence of the surface topography of the as-manufactured female taper surface on taper wear was examined by means of a multiple regression model, taking into account other known variables. RESULTS We identified great variation in the as-manufactured surface finish of the female taper surface, with a range of measured Ra values from 0.14 to 4.20 μm. The roughness of the female taper surface appeared to be the most important variable associated with taper wear (p < 0.001). The best-fitting regression model, including duration in vivo, head offset, reduced peak height (Rpk) value, stem shaft angle, and bearing surface wear rate, explained approximately 44% of the variation in taper wear rates. CONCLUSIONS We concluded that the roughness of the female taper surface appears to be a significant factor in metal debris release from head-stem taper junctions. CLINICAL RELEVANCE This study shows evidence that previously unappreciated variations in manufacturing processes may have a major impact on the clinical outcomes of patients.
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Affiliation(s)
- David Langton
- 1Farndale House, University Hospital of North Tees, Middlesbrough, England 2University Hospitals of Coventry and Warwickshire, Coventry, England 3Newcastle University, Newcastle Upon Tyne, England 4University Hospital of North Tees, Stockton-on-Tees, England 5Freeman Hospital, Newcastle Upon Tyne, England 6University Hospital of North Durham, Durham, England 7Sunderland Royal Hospital, Sunderland, England 8Queen Elizabeth Hospital, Gateshead, England 9Southern General Hospital, Glasgow, Scotland 10Nuffield Health Tees Hospital, Stockton-on-Tees, England
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The value of serial metal ion levels in following up patients with metal-on-metal hip arthroplasty. Hip Int 2017; 27:14-20. [PMID: 28106230 DOI: 10.5301/hipint.5000432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND The sensitivity of cobalt (Co) and chromium (Cr) ion-levels in detecting poorly performing metal-on-metal hip implants is low. This study proposes that serial changes in ion-levels are a more accurate marker of arthroplasties at risk. METHODS Serial metal ion-levels and implant data of 285 patients with ASR resurfacing or replacement were studied. Patient and implant characteristics were analysed using univariate and multivariate analyses. RESULTS 111 (39%) had revision surgery. Time since index surgery (p<0.001), acetabular inclination (p<0.001), their interaction (p<0.001) and femoral head size (p = 0.01) were significant variables. Head size (≤51 mm) had lower Co and Cr levels (p = 0.01). Cr/Co showed marginal decrease over time in the unrevised group and no decrease prerevision. CONCLUSIONS Repeated measurement of ion-levels were higher in the revision group suggesting that serial measurements rather than absolute values may have a role to play in predicting implant failure.
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Matharu GS, Berryman F, Brash L, Pynsent PB, Dunlop DJ, Treacy RBC. Can blood metal ion levels be used to identify patients with bilateral Birmingham Hip Resurfacings who are at risk of adverse reactions to metal debris? Bone Joint J 2017; 98-B:1455-1462. [PMID: 27803220 DOI: 10.1302/0301-620x.98b11.38042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 07/29/2016] [Indexed: 11/05/2022]
Abstract
AIMS We investigated whether blood metal ion levels could effectively identify patients with bilateral Birmingham Hip Resurfacing (BHR) implants who have adverse reactions to metal debris (ARMD). PATIENTS AND METHODS Metal ion levels in whole blood were measured in 185 patients with bilateral BHRs. Patients were divided into those with ARMD who either had undergone a revision for ARMD or had ARMD on imaging (n = 30), and those without ARMD (n = 155). Receiver operating characteristic analysis was used to determine the optimal thresholds of blood metal ion levels for identifying patients with ARMD. RESULTS The maximum level of cobalt or chromium ions in the blood was the parameter which produced the highest area under the curve (91.0%). The optimal threshold for distinguishing between patients with and without ARMD was 5.5 µg/l (83.3% sensitivity, 88.4% specificity, 58.1% positive and 96.5% negative predictive values). Similar results were obtained in a subgroup of 111 patients who all underwent cross-sectional imaging. Between 3.2% and 4.3% of patients with ARMD were missed if United Kingdom (7 µg/l) and United States (10 µg/l) authority thresholds were used respectively, compared with 2.7% if our implant specific threshold was used, though these differences did not reach statistical significance (p ≥ 0.248). CONCLUSION Patients with bilateral BHRs who have blood metal ion levels below our implant specific threshold were at low-risk of having ARMD. Cite this article: Bone Joint J 2016;98-B:1455-62.
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Affiliation(s)
- G S Matharu
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK and Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - F Berryman
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
| | - L Brash
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
| | - P B Pynsent
- University of Birmingham, Birmingham B15 2TT, UK
| | - D J Dunlop
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
| | - R B C Treacy
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
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Current expert views on metal-on-metal hip resurfacing arthroplasty. Consensus of the 6th advanced Hip resurfacing course, Ghent, Belgium, May 2014. Hip Int 2017; 26:1-7. [PMID: 26449333 DOI: 10.5301/hipint.5000288] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2015] [Indexed: 02/04/2023]
Abstract
This paper reports the consensus of an international faculty of expert metal-on-metal (MoM) hip resurfacing surgeons, with a combined experience of over 40,000 cases, on the current status of hip resurfacing arthroplasty. Indications, design and metallurgy issues, release of metal ions and adverse soft tissue reactions to particles, management of problematic cases and revisions, as well as required experience and training are covered. The overall consensus is that MoM hip resurfacing should not be banned and should be viewed separately from MoM total hip arthroplasty (THA) with a large diameter head because of the different design and wear behaviour related to the taper/trunnion connection. The use of hip resurfacing has decreased worldwide but specialist centres continue to advocate hip resurfacing in young and active male patients. Regarding age the general recommendation is to avoid hip resurfacing in men older than 65 and in women older than 55, depending on the patient activity and bone quality. Female gender is considered a relative contraindication. Most surgeons would not implant a MoM hip in women who would still like a child. Regardless of gender, there is a consensus not to perform hip resurfacing in case of a femoral head size smaller than 46 mm and in patients with renal insufficiency or with a known metal allergy. Regarding follow-up of hip resurfacing and detection of adverse local tissue reactions, metal ion measurements, MRI and ultrasound are advocated depending on the local expertise. The consensus is that hip resurfacing should be limited to high volume hip surgeons, who are experienced in hip resurfacing or trained to perform hip resurfacing in a specialist centre.
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Nakano N, Volpin A, Bartlett J, Khanduja V. Management Guidelines for Metal-on-metal Hip Resurfacing Arthroplasty: A Strategy on Followup. Indian J Orthop 2017; 51:414-420. [PMID: 28790470 PMCID: PMC5525522 DOI: 10.4103/ortho.ijortho_230_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Despite the initial promise of metal-on-metal (MoM) implants as the ideal bearing surface for hip replacements and resurfacings, high short term failure rates due to an adverse reaction to metal debris (ARMD) have led to a dramatic reduction in the number of MoM implants used in the modern era. With over one million patients worldwide having undergone hip operations utilizing a MoM bearing surface, the long term outcomes for such patients remains unknown, and there is much debate as to the most effective management of these patients. Although several regulatory bodies have released guidelines on the management of patients with MoM hips, these recommendations remain open to interpretation, and the most effective management for these patients remains unclear. The aim of this review is to compare the current guidelines for managing patients with MoM hips and also to discuss established ARMD risk factors, evidence regarding the optimum management for patients with MoM hips, and the indications for revision surgery. Furthermore, although specialized laboratory tests and imaging can be used to facilitate clinical decision making, over-reliance on any single tool should be avoided in the decision making process, and surgeons should carefully consider all findings when determining the most appropriate course of action.
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Affiliation(s)
- Naoki Nakano
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Andrea Volpin
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Jonathan Bartlett
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vikas Khanduja
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Address for correspondence: Mr. Vikas Khanduja, Consultant Orthopaedic Surgeon and Elective Clinical Trials Research Lead, Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Box 37, Hills Road, Cambridge, CB2 0QQ, UK. E-mail:
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Amanatullah DF, Sucher MG, Bonadurer GF, Pereira GC, Taunton MJ. Metal in Total Hip Arthroplasty: Wear Particles, Biology, and Diagnosis. Orthopedics 2016; 39:371-379. [PMID: 27459144 DOI: 10.3928/01477447-20160719-06] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 06/13/2016] [Indexed: 02/03/2023]
Abstract
Total hip arthroplasty (THA) has been performed for nearly 50 years. Between 2006 and 2012, more than 600,000 metal-on-metal THA procedures were performed in the United States. This article reviews the production of metal wear debris in a metal-on-metal articulation and the interaction of cobalt and chromium ions that ultimately led to a dramatic decline in the use of metal-on-metal THA articulations. Additionally, the article reviews mechanisms of metal wear, the biologic reaction to cobalt and chromium ions, the clinical presentation of failing metal-on-metal articulations, and current diagnostic strategies. Further, the article discusses the use of inflammatory markers, metal ion levels, radiographs, metal artifact reduction sequence magnetic resonance imaging, and ultrasound for failed metal-on-metal THA procedures. When adopting new technologies, orthopedic surgeons must weigh the potential increased benefits against the possibility of new mechanisms of failure. Metal-on-metal bearings are a prime example of the give and take between innovation and clinical results, especially in the setting of an already successful procedure such as THA. [Orthopedics. 2016; 39(6):371-379.].
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