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Sun CWY, Lau LCM, Cheung JPY, Choi SW. Cancer-Causing Effects of Orthopaedic Metal Implants in Total Hip Arthroplasty. Cancers (Basel) 2024; 16:1339. [PMID: 38611017 PMCID: PMC11011042 DOI: 10.3390/cancers16071339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Metal implants have been preferentially used in THA due to its biocompatibility, mechanical stability and durability. Yet concerns have emerged regarding their potential to release metallic ions, leading to long-term adverse effects, including carcinogenicity. This study aimed to investigate the risk of cancer development in patients with orthopaedic metal implants in total hip arthroplasty (THA). METHODS Patients with THA conducted at a local tertiary implant centre from 2001-2008 were linked to the local cancer registry and followed up to the end of 2023. Standardized incidence ratios (SIRs) for cancer incidence and its confidence interval by Poisson distribution were calculated. Survival analysis was depicted using the Kaplan-Meier method, and the log-rank test was used to assess the differences across groups. RESULTS The study cohort included 388 patients and 53 cancers diagnosed during follow-up, at least 5 years post THA. All-site cancer risks were increased in patients with THA (SIR: 1.97; 95% CI: 1.48-2.46), validated with chi-square analysis (chi-square = 15.2551, N = 100,388, p < 0.01). A statistically significant increase in multiple site-specific cancers including haematological cancers were identified. CONCLUSIONS Patients with THA were found to have an increased risk for cancer compared to the general population during a mean follow-up of 16 years.
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Affiliation(s)
| | | | | | - Siu-Wai Choi
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, Faculty of Medicine, The University of Hong Kong, Hong Kong, China; (C.W.Y.S.); (L.C.M.L.); (J.P.Y.C.)
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2
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Metselaar-Albers M, Meijerman I, Engels F, Haanen J, Beijnen J, Lalmohamed A. No detrimental association between antibiotic use and immune checkpoint inhibitor therapy: an observational cohort study comparing patients with ICI-treated and TKI-treated melanoma and NSCLC. J Immunother Cancer 2024; 12:e008269. [PMID: 38296595 PMCID: PMC10831429 DOI: 10.1136/jitc-2023-008269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND The role of antibiotics in malignancies treated with immune checkpoint inhibitors (ICI) remains unclear. Several studies suggested a detrimental impact of antibiotic use on the response to ICI, but were susceptible to confounding by indication. Our objective was therefore to assess whether the relationship between antibiotic use and ICI response is causative or merely associative. METHODS A large, single-center observational cohort study was performed with individuals treated for either non-small cell lung carcinoma (NSCLC) or metastatic melanoma. An effect modification approach was used, aiming to estimate the association between antibiotic use and overall survival (OS) and compare these estimates between individuals receiving first-line ICI treatment versus those receiving first-line tyrosine kinase inhibitors (TKIs). Exposure of interest was antibiotic use within 30 days before the start of anticancer treatment. HRs for OS were estimated for antibiotics versus no antibiotics in each cohort using multivariable propensity adjusted analysis. The "true antibiotic effect" within the ICI versus TKI cohort was modeled using an interaction term. RESULTS A total of 4534 patients were included, of which 1908 in the ICI cohort and 817 in the TKI cohort. Approximately 10% of patients in each cohort used antibiotics within 30 days before the start of anticancer treatment. Our results demonstrate a lack of synergistic interaction between current antibiotic use and ICI therapy in relation to OS: although antibiotic use was significantly associated with OS decline in the ICI cohort (HR=1.26 (95% CI 1.04 to 1.51)), a similar magnitude in OS decline was found within the TKI cohort (HR=1.24 (95% CI 0.95 to 1.62)). This was reflected by the synergy index (HR=0.96 (95% CI 0.70 to 1.31)), which implied no synergistic interaction between current antibiotic use and ICI. CONCLUSION This study strongly suggests that there is no causal detrimental association between antibiotic use and ICI therapy outcome when looking at OS in individuals with malignant melanoma or NSCLC. The frequently observed inverse association between antibiotics and ICI response in previous studies is most likely driven by confounding by indication, which was confirmed by the findings in our reference TKI cohort.
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Affiliation(s)
| | - Irma Meijerman
- Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Ferdi Engels
- Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - John Haanen
- Medical Oncology, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands
| | - Jos Beijnen
- Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Arief Lalmohamed
- Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Clinical Pharmacy, Utrecht University, Utrecht, The Netherlands
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Pratt NL, Cicuttini FM, Wang Y, Graves SE. No increased risk of cancer associated with metal-on-metal or ceramic-on-ceramic procedures compared to other bearing surfaces in patients with total hip arthroplasty: A nationwide linked registry cohort analysis of 167,837 patients. PLoS One 2022; 17:e0278241. [PMID: 36449468 PMCID: PMC9710777 DOI: 10.1371/journal.pone.0278241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/14/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Studies have identified increased cancer risk among patients undergoing total hip arthroplasty (THA) compared to the general population. However, evidence of all-cause and site-specific cancer risk associated with different bearing surfaces has varied, with previous studies having short latency periods with respect to use of modern Metal-on-Metal (MoM) bearings. Using the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) linked to Australasian Association of Cancer Registries data, our aim was to evaluate risk of all-cause and site-specific cancer according to bearing surfaces in patients undergoing THA for osteoarthritis and whether risk increased with MoM bearings. METHODS Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated by comparing number of observed cancer cases to expected number based on incidence rate in the Australian population. All-cause and site-specific cancer rates were calculated for all conventional stemmed THA (csTHA) and resurfacing THA (rsTHA) procedures performed for osteoarthritis. Cox proportional hazards models were used to compare cancer rates for MoM, ceramic-on-ceramic (CoC) and resurfacing procedures with a comparison group comprising metal-on-polyethylene (MoP) or ceramic-on-polyethylene (CoP) procedures. RESULTS There were 156,516 patients with csTHA procedures and 11,321 with rsTHA procedures for osteoarthritis performed between 1999 and 2012. Incidence of all-cause cancer was significantly higher for csTHA (SIR 1.24, 95% CI 1.22-1.26) and rsTHA (SIR 1.74, 95% CI 1.39-2.04) compared to the Australian population. For csTHA, there was no significant difference in all-site cancer rates for MoM (Hazard Ratio (HR) 1.01, 95%CI 0.96-1.07) or CoC (HR 0.98, 95%CI 0.94-1.02) compared to MoP and CoP bearings. Significantly increased risk of melanoma, non-Hodgkins lymphoma, myeloma, leukaemia, prostate, colon, bladder and kidney cancer was found for csTHA and, prostate cancer, melanoma for rsTHA procedures when compared to the Australian population, although risk was not significantly different across bearing surfaces. CONCLUSIONS csTHA and rsTHA procedures were associated with increased cancer incidence compared to the Australian population. However, no excess risk was observed for MoM or CoC procedures compared to other bearing surfaces.
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Affiliation(s)
- Nicole L. Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
- * E-mail:
| | - Flavia M. Cicuttini
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yuanyuan Wang
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen E. Graves
- Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Zhang S, Holy CE, Eichenbaum G, Perkins LE, Hasgall P, Katz LB, Brown JR, Orlandini L, Fessel G, Nasseri-Aghbosh B, Egnot NS, Zhou M, Beech R, Marcello SR, Coplan PM. Carcinogenic assessment of cobalt-containing alloys in medical devices or cobalt in occupational settings: A systematic review and meta-analysis of overall cancer risk from published epidemiologic studies. Regul Toxicol Pharmacol 2021; 125:104987. [DOI: 10.1016/j.yrtph.2021.104987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 02/07/2023]
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5
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Carcinogenic hazard assessment of cobalt-containing alloys in medical devices: Review of in vivo studies. Regul Toxicol Pharmacol 2021; 122:104910. [DOI: 10.1016/j.yrtph.2021.104910] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/03/2021] [Accepted: 02/24/2021] [Indexed: 11/19/2022]
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Bozza N, Guindani N, Pezzotta G, Alberto F, Castelli CC. 15-year follow-up of MoM 36-mm THA: clinical, laboratory, and radiological (CT and MRI) prospective assessment. Hip Int 2020; 30:42-51. [PMID: 33267695 DOI: 10.1177/1120700020971662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION There is limited knowledge of the long-term results of metal-on-metal total hip arthroplasty (MoM THA), particularly concerning adverse local tissue reaction (ALTR), Co/Cr ions level and revision rate. Even if MoM bearing surfaces are no longer used, long-term data could help in defining the course and best management for these patients. The purpose of this study is to investigate the clinical outcomes, describe radiological findings including CT metal artefact reduction algorithm for orthopaedic implants (O-MAR) and MRI multi acquisition variable resonance image combination (MAVRIC) in 36-mm MoM THA. METHODS In this long-term prospective study, 46 consecutive patients with primary MoM THA (mono- or bilateral) were enrolled between 2004 and 2005. Pinnacle acetabular cup, Summit cementless stem with 36-mm metal head and Ultamet CoCr alloy liner (Depuy Inc.) were implanted, in the same centre by the same senior surgeon. Patients were reviewed at 5-, 10- and 15-years, including Co/Cr levels and standard radiographs at every follow-up, whilst the 15-year follow-up included hip sonography, MRI MAVRIC and CT O-MAR. RESULTS At 15 years, the overall survival rate of the implants (both stems and cups) was 83% (30/36). Revisions were performed in 9% (4/46) because of ALTR, 2% (1/46) septic loosening and 2% periprosthetic fracture. Both Cr and Co concentration increased over time, even though remaining at low level risk at 15 years: Co from 0.11 (+/- 0.18) to 4.29 (+/- 3.26) and Cr from 0.38 (+/- 0.32) to 1.37 (+/- 1.15). Functional scores in non-revised patients showed good to excellent results in more than 90%. Engh-score correlated with time from surgery (p = 0.017) and with sonographic, CT and RM findings (p < 0.05). Concordance has been found between CT and MRI findings (sign-rank test, p = 0.241; Intraclass Correlation Coefficients 0.987); however, no specific MRI or CT lesion patterns could be recognised among symptomatic and non-symptomatic patients. DISCUSSION The long-term rate of ALTR after 36-mm MoM THA was comparable with previous studies; a regular follow-up for those implants is mandatory. During follow-up Co-Cr levels increased over time and radiography was a suitable screening technique; the Engh score in particular, proved to be a reliable assessment tool. CT O-MAR and MRI with MAVRIC protocols may add valuable data in clinical practice, although MRI is significantly more efficient than CT in the identification of ALTR lesions, peri-articular effusion and in the evaluation of soft tissues.
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Affiliation(s)
- Nicola Bozza
- Surgical Department, Orthopaedics and Traumatology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Nicola Guindani
- Surgical Department, Orthopaedics and Traumatology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Giuseppe Pezzotta
- Surgical Department, Orthopaedics and Traumatology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ferrari Alberto
- Fondazione per la Ricerca Ospedale di Bergamo (FROM), Bergamo, Italy
| | - Claudio C Castelli
- Surgical Department, Orthopaedics and Traumatology, Papa Giovanni XXIII Hospital, Bergamo, Italy
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D'Ambrosi R, Ursino N. N-Acetyl-Cysteine Reduces Blood Chromium and Cobalt Levels in Metal-on-Metal Hip Arthroplasty. Arthroplast Today 2020; 6:149-152. [PMID: 32346587 PMCID: PMC7183002 DOI: 10.1016/j.artd.2020.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/11/2020] [Accepted: 03/14/2020] [Indexed: 11/27/2022] Open
Abstract
The most common reasons for revision of metal-on-metal hip arthroplasty are aseptic loosening and metal reaction. Failure of a metal-on-metal implant due to the aggressive destruction of periprosthetic tissues may require extensive reconstruction procedures. The aim of this case report is to describe the treatment in an asymptomatic patient with high levels of chromium and cobalt, using chelation therapy. The rational use of N-acetyl-cysteine (NAC) involves thiol groups to chelate sites for metals. More than 10 years after the metal-on-metal hip arthroplasty, the patient did not have to undergo revision surgery; the levels of the ions in the blood were considerably lowered (chromium from 4.51 mcg/L to 1.85 mcg/L; cobalt from 7.78 UG/L to 0.8 UG/L) after using NAC without adverse effects.
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8
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Eltit F, Wang Q, Wang R. Mechanisms of Adverse Local Tissue Reactions to Hip Implants. Front Bioeng Biotechnol 2019; 7:176. [PMID: 31417898 PMCID: PMC6683860 DOI: 10.3389/fbioe.2019.00176] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/08/2019] [Indexed: 12/11/2022] Open
Abstract
Adverse Local Tissue Reactions (ALTRs) are one of the main causes of hip implant failures. Although the metal release from the implants is considered as a main etiology, the mechanisms, and the roles of the released products are topics of ongoing research. The alloys used in the hip implants are considered biocompatible and show negligible corrosion in the body environment under static conditions. However, modularity and its associated mechanically assisted corrosion have been shown to release metal species into the body fluids. ALTRs associated with metal release have been observed in hip implants with metal-on-metal articulation initially, and later with metal-on-polyethylene articulation, the most commonly used design in current hip replacement. The etiological factors in ALTRs have been the topics of many studies. One commonly accepted theory is that the interactions between the metal species and body proteins and cells generate a delayed type IV hypersensitivity reaction leading to ALTRs. However, lymphocyte reactions are not always observed in ALTRS, and the molecular mechanisms have not been clearly demonstrated. A more accepted mechanism is that cell damage generated by metal ions may trigger the secretion of cytokines leading to the inflammatory reactions observed in ALTRs. In this inflammatory environment, some patients would develop hypersensitivity that is associated with poor outcomes. Concerns over ALTRS have brought significant impact to both the clinical selection and development of hip implants. This review is focused on the mechanisms of ALTRs, specifically, the metal release process and the roles of the metal species released in the etiology and pathogenesis of the disease. Hopefully, our presentation and discussion of this biological process from a material perspective could improve our current understanding on the ALTRs and provide useful guidance in developing preventive solutions.
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Affiliation(s)
- Felipe Eltit
- Department of Materials Engineering, University of British Columba, Vancouver, BC, Canada.,School of Biomedical Engineering, University of British Columba, Vancouver, BC, Canada.,Centre for Hip Health and Mobility, Vancouver, BC, Canada
| | - Qiong Wang
- Department of Materials Engineering, University of British Columba, Vancouver, BC, Canada.,School of Biomedical Engineering, University of British Columba, Vancouver, BC, Canada.,Centre for Hip Health and Mobility, Vancouver, BC, Canada
| | - Rizhi Wang
- Department of Materials Engineering, University of British Columba, Vancouver, BC, Canada.,School of Biomedical Engineering, University of British Columba, Vancouver, BC, Canada.,Centre for Hip Health and Mobility, Vancouver, BC, Canada
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9
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Ekman E, Laaksonen I, Eskelinen A, Pulkkinen P, Pukkala E, Mäkelä K. Midterm risk of cancer with metal-on-metal hip replacements not increased in a Finnish population. Acta Orthop 2018; 89:575-579. [PMID: 29912603 PMCID: PMC6202763 DOI: 10.1080/17453674.2018.1487202] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Metal-on-metal (MoM) total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) have been widely used during the early 21st century. We assessed the midterm risk of cancer of patients treated with modern MoM hip implants compared with patients with non-MoM hip implants and the general Finnish population with special interest in soft tissue sarcomas and basalioma due to the findings of our previous report. Patients and methods - All large-diameter head MoM THAs and hip resurfacings performed in Finland between 2001 and 2010 were extracted from the Finnish Arthroplasty Register (10,728 patients). Patients who underwent conventional THA formed the non-MoM reference cohort (18,235 patients). Data on cancer cases up to 2014 were extracted from the Finnish Cancer Registry. The relative risk of cancer in the general population was expressed as the ratio of observed to expected number of cases, i.e., standardized incidence ratio (SIR). Poisson regression analysis was used to compare the cancer risk between the cohorts. The mean follow-up was 7.4 years (1-14) in the MoM cohort and 8.4 years (1-14) in the non-MoM cohort. Results - The overall risk of cancer in the MoM cohort was comparable to the general Finnish population (SIR 0.9, 95% CI 0.9-1.0). Risk of basalioma in the MoM cohort was higher than in the general Finnish population (SIR 1.2, CI 1.1-1.4) and higher than in the non-MoM cohort in the stratified regression analysis (RR 1.2, CI 1.0-1.4, p = 0.02). The SIR of soft-tissue sarcoma in the MoM cohort was 1.4 (CI 0.6-2.8); the incidence was same as in the non-MoM cohort. Interpretation - Metal-on-metal hip implants are not associated with an increased overall risk of cancer during midterm follow-up.
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Affiliation(s)
- Elina Ekman
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku; ,Correspondence:
| | - Inari Laaksonen
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku;
| | | | | | - Eero Pukkala
- Faculty of Social Sciences, University of Tampere, Tampere; ,The Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
| | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku;
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10
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Hunt LP, Blom AW, Matharu GS, Porter ML, Whitehouse MR. The risk of developing cancer following metal-on-metal hip replacement compared with non metal-on-metal hip bearings: Findings from a prospective national registry "The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man". PLoS One 2018; 13:e0204356. [PMID: 30235326 PMCID: PMC6147563 DOI: 10.1371/journal.pone.0204356] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 09/06/2018] [Indexed: 12/13/2022] Open
Abstract
Background and purpose Over 1 million metal-on-metal hip replacements were implanted. Even well-functioning implants produce wear debris that can cause tissue damage, disseminate and cause DNA damage. We aimed to establish if there was an association between metal-on-metal hip replacement and the risk of subsequently developing cancer compared with alternative hip replacements. Methods We performed a population based prospective longitudinal cohort study using data from the National Joint Registry linked to Hospital Episode Statistics (n = 403,881 patients). We examined the incidence of a new diagnosis of cancer in patients who received a metal-on-metal bearing in comparison with those who received a non metal-on-metal bearing. Kaplan-Meier estimates of time to first cancer diagnosis were used with Cox proportional hazards regression models to assess the effect on the time to cancer diagnosis for all cancer types, haematological, malignant melanoma, urinary tract cancers or prostate cancer in men. Results The maximum follow up available was 11.8 years with 25% of patients followed up for more than 6.8 years (mean follow up 4.6 years; median 4.3; IQR 2.1–6.8; range 0.01–11.8). Analyses by gender that adjusted for age at primary and presence or absence of linked Welsh (PEDW) records showed no increase in the risk of developing cancer according to the bearing surface implanted for all cancers, haematological cancers, malignant melanoma, urinary tract cancers or prostate cancer in men. For patients receiving a second hip replacement, there was also no difference. Conclusion We have demonstrated that there is currently no evidence of an increase in the risk of cancer following primary hip replacement according to the type of bearing material used. Although the risk of revision in metal-on-metal bearing hip replacements is higher, it is reassuring that the risk of a new diagnosis of cancer is not currently increased. Despite the long term follow up available in this study, the latency period for some cancers is very long and therefore continued monitoring is required to ensure no new patterns emerge that may indicate need for universal screening.
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Affiliation(s)
- Linda P. Hunt
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol & Southmead Hospital, Bristol, United Kingdom
| | - Ashley W. Blom
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol & Southmead Hospital, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
| | - Gulraj S. Matharu
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol & Southmead Hospital, Bristol, United Kingdom
| | - Martyn L. Porter
- Centre for Hip Surgery, Wrightington Hospital, Wrightington, Lancashire, United Kingdom
- * E-mail: (MRW); (MLP)
| | - Michael R. Whitehouse
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol & Southmead Hospital, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
- * E-mail: (MRW); (MLP)
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11
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Sabah SA, Moon JC, Jenkins-Jones S, Morgan CL, Currie CJ, Wilkinson JM, Porter M, Captur G, Henckel J, Chaturvedi N, Kay P, Skinner JA, Hart AJ, Manisty C. The risk of cardiac failure following metal-on-metal hip arthroplasty. Bone Joint J 2018; 100-B:20-27. [PMID: 29305446 PMCID: PMC6424145 DOI: 10.1302/0301-620x.100b1.bjj-2017-1065.r1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIMS The aim of this study was to determine whether patients with metal-on-metal (MoM) arthroplasties of the hip have an increased risk of cardiac failure compared with those with alternative types of arthroplasties (non-MoM). PATIENTS AND METHODS A linkage study between the National Joint Registry, Hospital Episodes Statistics and records of the Office for National Statistics on deaths was undertaken. Patients who underwent elective total hip arthroplasty between January 2003 and December 2014 with no past history of cardiac failure were included and stratified as having either a MoM (n = 53 529) or a non-MoM (n = 482 247) arthroplasty. The primary outcome measure was the time to an admission to hospital for cardiac failure or death. Analysis was carried out using data from all patients and from those matched by propensity score. RESULTS The risk of cardiac failure was lower in the MoM cohort compared with the non-MoM cohort (adjusted hazard ratio (aHR) 0.901; 95% confidence interval (CI) 0.853 to 0.953). The risk of cardiac failure was similar following matching (aHR 0.909; 95% CI 0.838 to 0.987) and the findings were consistent in subgroup analysis. CONCLUSION The risk of cardiac failure following total hip arthroplasty was not increased in those in whom MoM implants were used, compared with those in whom other types of prostheses were used, in the first seven years after surgery. Cite this article: Bone Joint J 2018;100-B:20-7.
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Affiliation(s)
- S A Sabah
- Royal National Orthopaedic Hospital, Stanmore, Middlesex and University College London, London, UK
| | - J C Moon
- Institute of Cardiovascular Sciences, University College London and Barts Heart Centre, London, UK
| | - S Jenkins-Jones
- Division of Surgery and Interventional Sciences, University College London, UK and Global Epidemiology and Medical Statistics, Pharmatelligence, Cardiff, UK
| | - C Ll Morgan
- Division of Surgery and Interventional Sciences, University College London, UK and Global Epidemiology and Medical Statistics, Pharmatelligence, Cardiff, UK
| | - C J Currie
- Global Epidemiology and Medical Statistics, Pharmatelligence, Cardiff, UK and Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - J M Wilkinson
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK and National Joint Registry for England, Wales and Northern Ireland
| | - M Porter
- Centre for Hip Surgery, Wrightington Hospital, Wigan, UK
| | - G Captur
- Institute of Cardiovascular Sciences, University College London, UK and Department of Cardiology, Barts Heart Centre, London, UK
| | - J Henckel
- Royal National Orthopaedic Hospital, Stanmore, UK and Division of Surgery and Interventional Sciences, University College London, UK
| | - N Chaturvedi
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - P Kay
- Wrightington Hospital, Wigan, UK
| | - J A Skinner
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - A J Hart
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - C Manisty
- Institute of Cardiovascular Sciences, University College London, UK and Department of Cardiology, Barts Heart Centre, London, UK
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12
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Lübbeke A, Silman AJ, Prieto-Alhambra D, Adler AI, Barea C, Carr AJ. The role of national registries in improving patient safety for hip and knee replacements. BMC Musculoskelet Disord 2017; 18:414. [PMID: 29037237 PMCID: PMC5644143 DOI: 10.1186/s12891-017-1773-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 10/04/2017] [Indexed: 12/12/2022] Open
Abstract
Background The serious adverse events associated with metal on metal hip replacements have highlighted the importance of improving methods for monitoring surgical implants. The new European Union (EU) device regulation will enforce post-marketing surveillance based on registries among other surveillance tools. Europe has a common regulatory environment, a common market for medical devices, and extensive experience with joint replacement registries. In this context, we elaborate how joint replacement registries, while building on existing structure and data, can better ensure safety and balance risks and benefits. Main text Actions to improve registry-based implant surveillance include: enriching baseline and diversifying outcomes data collection; improving methodology to limit bias; speeding-up failure detection by active real-time monitoring; implementing risk-benefit analysis; coordinating collaboration between registries; and translating knowledge gained from the data into clinical decision-making and public health policy. Conclusions The changes proposed here will improve patient safety, enforce the application of the new legal EU requirements, augment evidence, improve clinical decision-making, facilitate value-based health-care delivery, and provide up-to-date guidance for public health.
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Affiliation(s)
- Anne Lübbeke
- Division of Orthopaedic Surgery and Traumatology, Geneva University Hospitals and Geneva University, Geneva, Switzerland. .,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Alan J Silman
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amanda I Adler
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,National Institute for Health and Care Excellence, 10 Spring Gardens, London, UK
| | - Christophe Barea
- Division of Orthopaedic Surgery and Traumatology, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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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: 402] [Impact Index Per Article: 57.4] [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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14
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Pijls BG, Meessen JMTA, Schoones JW, Fiocco M, van der Heide HJL, Sedrakyan A, Nelissen RGHH. Increased Mortality in Metal-on-Metal versus Non-Metal-on-Metal Primary Total Hip Arthroplasty at 10 Years and Longer Follow-Up: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0156051. [PMID: 27295038 PMCID: PMC4905643 DOI: 10.1371/journal.pone.0156051] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 05/09/2016] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE There are concerns about increased mortality in patients with metal-on-metal bearings in total hip arthroplasty (THA). OBJECTIVE To determine the mortality and the morbidity in patients with metal-on-metal articulations (MOM THA) compared to patients with non-metal-on-metal articulations (non-MOM THA) after primary total hip arthroplasty. DATA SOURCES Search of PubMed, MEDLINE, EMBASE, Web of Science, Cochrane, CINAHL, AcademicSearchPremier, ScienceDirect, Wiley and clinical trial registers through March 2015, augmented by a hand search of references from the included articles. No language restrictions were applied. STUDY SELECTION Two reviewers screened and identified randomised controlled trials and observational studies of primary total hip arthroplasty comparing MOM THA with non-MOM THA. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted study data and assessed risk of bias. Risk differences (RD) were calculated with random effect models. Meta-regression was used to explore modifying factors. MAIN OUTCOMES AND MEASURES Difference in mortality and difference in morbidity expressed as revisions and medical complications between patients with MOM THA and non-MOM THA. RESULTS Forty-seven studies were included, comprising 4,000 THA in randomised trials and over 500,000 THA in observational studies. For mortality, random effects analysis revealed a higher pooled RD of 0.7%, 95%, confidence interval (CI) [0.0%, 2.3%], I-square 42%; the heterogeneity was explained by differences in follow-up. When restricted to studies with long term follow-up (i.e. 10 years or more), the RD for mortality was 8.5%, 95%, CI [5.8%, 11.2%]; number needed to treat was 12. Further subgroup analyses and meta-regression random effects models revealed no evidence for other moderator variables (study level covariates, e.g. resurfacing vs. non-resurfacing MOM) than follow-up duration. The quality of the evidence presented in this meta-analysis was characterized as moderate according to the CLEAR-NPT (for non-pharmacological trials) and Cochrane risk of bias Table. CONCLUSIONS AND RELEVANCE Meta-analysis suggests there may be an increased long-term risk of mortality and revision surgery for patients with MOM THA compared to patients with non-MOM THA. REGISTRATION PROSPERO 2014:CRD42014007417.
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Affiliation(s)
- B G Pijls
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M T A Meessen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - J W Schoones
- Walaeus Library, Leiden University Medical Centre, Leiden, The Netherlands
| | - M Fiocco
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
- Mathematical Institute, Leiden University, Leiden, The Netherlands
| | - H J L van der Heide
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - A Sedrakyan
- FDA Medical Device Epidemiology (MDEpiNet) Science and Infrastructure Center, U.S. Food and Drug Administration, Silver Spring, MD, United States of America
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - R G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
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Beddoes CM, Whitehouse MR, Briscoe WH, Su B. Hydrogels as a Replacement Material for Damaged Articular Hyaline Cartilage. MATERIALS (BASEL, SWITZERLAND) 2016; 9:E443. [PMID: 28773566 PMCID: PMC5456752 DOI: 10.3390/ma9060443] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 05/24/2016] [Accepted: 05/30/2016] [Indexed: 12/12/2022]
Abstract
Hyaline cartilage is a strong durable material that lubricates joint movement. Due to its avascular structure, cartilage has a poor self-healing ability, thus, a challenge in joint recovery. When severely damaged, cartilage may need to be replaced. However, currently we are unable to replicate the hyaline cartilage, and as such, alternative materials with considerably different properties are used. This results in undesirable side effects, including inadequate lubrication, wear debris, wear of the opposing articular cartilage, and weakening of the surrounding tissue. With the number of surgeries for cartilage repair increasing, a need for materials that can better mimic cartilage, and support the surrounding material in its typical function, is becoming evident. Here, we present a brief overview of the structure and properties of the hyaline cartilage and the current methods for cartilage repair. We then highlight some of the alternative materials under development as potential methods of repair; this is followed by an overview of the development of tough hydrogels. In particular, double network (DN) hydrogels are a promising replacement material, with continually improving physical properties. These hydrogels are coming closer to replicating the strength and toughness of the hyaline cartilage, while offering excellent lubrication. We conclude by highlighting several different methods of integrating replacement materials with the native joint to ensure stability and optimal behaviour.
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Affiliation(s)
- Charlotte M Beddoes
- School of Oral and Dental Sciences, University of Bristol, Lower Maudlin Street, Bristol BS1 2LY, UK.
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Bristol BS10 5NB, UK.
| | - Wuge H Briscoe
- School of Chemistry, University of Bristol, Cantock's Close, Bristol BS8 1TS, UK.
| | - Bo Su
- School of Oral and Dental Sciences, University of Bristol, Lower Maudlin Street, Bristol BS1 2LY, UK.
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16
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Knapen LM, van Dalem J, Keulemans YC, van Erp NP, Bazelier MT, De Bruin ML, Leufkens HGM, Croes S, Neef C, de Vries F, Driessen JHM. Use of incretin agents and risk of pancreatic cancer: a population-based cohort study. Diabetes Obes Metab 2016; 18:258-65. [PMID: 26537555 DOI: 10.1111/dom.12605] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 10/21/2015] [Accepted: 11/02/2015] [Indexed: 01/14/2023]
Abstract
AIM To investigate the association between the use of incretin agents and the risk of pancreatic cancer. METHODS A retrospective population-based cohort study, using data from the Clinical Practice Research Datalink, 2007-2012, was conducted. Patients (n = 182 428) with at least one non-insulin antidiabetic drug (NIAD) prescription and aged ≥18 years during data collection, were matched one-to-one to control patients without diabetes. Multivariable Cox proportional hazards models and a new user design were used to estimate the hazard ratio (HR) of pancreatic cancer in incretin users (n = 28 370) compared with control subjects without diabetes and other NIAD-treated patients. Time-dependent adjustments were made for age, sex, lifestyle, comorbidities and drug use. RESULTS The mean duration of follow-up was 4.1 years for incretin users. Current NIAD use was associated with a fourfold increased risk of pancreatic cancer [HR 4.28, 95% confidence interval (CI) 3.49-5.24]. This risk was almost doubled among current incretin users as compared with control subjects. Incretin use was not associated with pancreatic cancer when compared with control subjects with diabetes (HR 1.36, 95% CI 0.94-1.96); however, the 'new user' design did show an association between incretin use and pancreatic cancer when compared with control subjects with diabetes. In both cohorts with prevalent and incident users of antidiabetic drugs, the risk of pancreatic cancer almost doubled in those who had recently initiated incretin therapy (up to seven prescriptions), whereas this elevated risk dropped to baseline levels with prolonged use. CONCLUSIONS We found that incretin use was not associated with pancreatic cancer after adjustment for the severity of the underlying Type 2 Diabetes Mellitus (T2DM). The elevated risk of pancreatic cancer in those recently initiating incretin agents is likely to be caused by protopathic bias or other types of unknown distortion. The presence of considerable confounding by disease severity and the lack of a duration-of-use relationship do not support a causal explanation for the association between incretin agents and pancreatic cancer.
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Affiliation(s)
- L M Knapen
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J van Dalem
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Y C Keulemans
- Department of Gastroenterology, Zuyderland, Heerlen, Netherlands
| | - N P van Erp
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M T Bazelier
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - M L De Bruin
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - H G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - S Croes
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - C Neef
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - F de Vries
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
| | - J H M Driessen
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
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17
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Cheung AC, Banerjee S, Cherian JJ, Wong F, Butany J, Gilbert C, Overgaard C, Syed K, Zywiel MG, Jacobs JJ, Mont MA. Systemic cobalt toxicity from total hip arthroplasties. Bone Joint J 2016; 98-B:6-13. [PMID: 26733509 DOI: 10.1302/0301-620x.98b1.36374] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Recently, the use of metal-on-metal articulations in total hip arthroplasty (THA) has led to an increase in adverse events owing to local soft-tissue reactions from metal ions and wear debris. While the majority of these implants perform well, it has been increasingly recognised that a small proportion of patients may develop complications secondary to systemic cobalt toxicity when these implants fail. However, distinguishing true toxicity from benign elevations in cobalt ion levels can be challenging. The purpose of this two part series is to review the use of cobalt alloys in THA and to highlight the following related topics of interest: mechanisms of cobalt ion release and their measurement, definitions of pathological cobalt ion levels, and the pathophysiology, risk factors and treatment of cobalt toxicity. Historically, these metal-on-metal arthroplasties are composed of a chromium-cobalt articulation. The release of cobalt is due to the mechanical and oxidative stresses placed on the prosthetic joint. It exerts its pathological effects through direct cellular toxicity. This manuscript will highlight the pathophysiology of cobalt toxicity in patients with metal-on-metal hip arthroplasties. Take home message: Patients with new or evolving hip symptoms with a prior history of THA warrant orthopaedic surgical evaluation. Increased awareness of the range of systemic symptoms associated with cobalt toxicity, coupled with prompt orthopaedic intervention, may forestall the development of further complications. Cite this article: Bone Joint J 2016;98-B:6–13.
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Affiliation(s)
- A. C. Cheung
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - S. Banerjee
- Sinai Hospital of Baltimore, 2401 West
Belvedere Avenue, Baltimore, Maryland, USA
| | - J. J. Cherian
- Sinai Hospital of Baltimore, 2401 West
Belvedere Avenue, Baltimore, Maryland, USA
| | - F. Wong
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - J. Butany
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - C. Gilbert
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - C. Overgaard
- University of Toronto, 200
Elizabeth Street, Toronto, Ontario, M5G
2C4, Canada
| | - K. Syed
- University of Toronto, 100
College Street Room 302, Toronto, Ontario, M5G
1L5, Canada
| | - M. G. Zywiel
- University of Toronto, 100
College Street Room 302, Toronto, Ontario, M5G
1L5, Canada
| | - J. J. Jacobs
- Rush
University, 1611 W. Harrison St., Suite
400, Chicago, IL60612, USA
| | - M. A. Mont
- Sinai Hospital of Baltimore, 2401 West
Belvedere Avenue, Baltimore, Maryland, USA
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18
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Nielen JT, van den Bemt BJF, Boonen A, Dagnelie PC, Emans PJ, Veldhorst N, Lalmohamed A, van Staa TP, de Vries F. Identification of antithrombotic drugs related to total joint replacement using anonymised free-text notes: a search strategy in the Clinical Practice Research Datalink. BMJ Open 2015; 5:e009017. [PMID: 26621515 PMCID: PMC4679841 DOI: 10.1136/bmjopen-2015-009017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES We aimed to design and test a method to extract information on antithrombotic therapy from anonymised free-text notes in the Clinical Practice Research Datalink (CPRD). SETTING General practice database representative of the UK. PARTICIPANTS All patients undergoing total hip replacement (THR, n=25,898) or total knee replacement (TKR, n=22,231) between January 2008 and October 2012 were included. Antithrombotic drug use related to THR or TKR was identified using anonymised free text and prescription data. PRIMARY AND SECONDARY OUTCOME MEASURES Internal validity of our newly designed method was determined by calculating positive predictive values (PPVs) of hits for predefined keywords in a random sample of anonymised free-text notes. In order to determine potential detection bias, total joint replacement (TJR) patient characteristics were compared as per their status of exposure to antithrombotics. RESULTS PPVs ranging between 97% and 99% for new oral anticoagulants (NOAC) or low-molecular weight heparins (LMWH) exposure related to TJR were obtained with our method. Our search strategy increased detection rates by 57%, yielding a total proportion of 18.5% of all THR and 18.6% of all TKR surgeries. Identified users of NOACs and LMWHs were largely similar with regards to age, sex, lifestyle, disease and drug history compared to patients without identified drug use. CONCLUSIONS We have developed a useful method to identify additional exposure to NOACs or LMWHs with TJR surgery.
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Affiliation(s)
- Johannes Th Nielen
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Pieter C Dagnelie
- Department of Epidemiology, CAPHRI School for Public Health and Primary Care, and CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Pieter J Emans
- Department of Orthopaedics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nicole Veldhorst
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tjeerd-Pieter van Staa
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Frank de Vries
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, Maastricht, The Netherlands
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Jørgensen CC, Jans Ø, Kehlet H. Preoperative anaemia and newly diagnosed cancer 1 year after elective total hip and knee arthroplasty. Vox Sang 2015; 109:62-70. [PMID: 25975629 DOI: 10.1111/vox.12255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/04/2015] [Accepted: 01/10/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Preoperative anaemia is a well-established risk factor for use of blood transfusions and postoperative morbidity. Consequently, focus on preoperative evaluation of haemoglobin levels is increasing. In this context, iron deficiency anaemia may be a symptom of undiscovered gastrointestinal (GI) cancer requiring further investigation. However, the association between preoperative anaemia and cancer 1 year after elective total hip (THA) and total knee arthroplasty (TKA) is unknown. We evaluated 1-year cancer diagnoses, particularly GI cancers, in anaemic and non-anaemic THA and TKA patients. STUDY DESIGN AND METHODS A prospective database on preoperative patient characteristics from six Danish orthopaedic centres was cross-referenced with the Danish Cancer Registry for information on diagnoses of new cancers 1 year after surgery. Crude cancer risk estimates were calculated using chi-square and Fisher's exact test in the total study cohort. Adjusted risk estimates were obtained using propensity scores and the Mantel-Haenzel statistic. RESULTS Of 5400 procedures, 731 (13·5%) were in anaemic patients. These were older and had more comorbidity than non-anaemic patients. There were 17 (2·3%) and 79 (1·6%) new cancers in anaemic and non-anaemic patients, respectively (OR: 1·38; 95% CI: 0·81-2·35, P = 0·228). After propensity matching of 661 anaemic and 1305 non-anaemic patients, we found no association between preoperative anaemia and cancer (OR: 0·94; 95% CI: 0·51-1·73, P = 0·837) or with GI cancers specifically (OR: 0·80; 95% CI: 0·25-2·56, P = 0·707). CONCLUSION Preoperative anaemia per se may not be related to being diagnosed with cancer 1 year after THA and TKA. The optimal criteria for preoperative referral of anaemic patients to gastroenterologist in elective THA and TKA need further investigation.
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Affiliation(s)
- C C Jørgensen
- Section for Surgical Pathophysiology 4074, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.,The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
| | - Ø Jans
- Section for Surgical Pathophysiology 4074, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.,The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
| | - H Kehlet
- The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
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How do metal ion levels change over time in hip resurfacing patients? A cohort study. ScientificWorldJournal 2014; 2014:291925. [PMID: 25580456 PMCID: PMC4279264 DOI: 10.1155/2014/291925] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 11/27/2014] [Indexed: 01/15/2023] Open
Abstract
Metal-on-metal hip resurfacing (MOM-HR) is offered as an alternative to traditional hip arthroplasty for young, active adults with advanced osteoarthritis. Nevertheless, concerns remain regarding wear and corrosion of the bearing surfaces and the resulting increase in metal ion levels. We evaluated three cohorts of patients with Birmingham hip resurfacing (BHR) at an average follow-up of 2, 5, and 9 years. We asked whether there would be differences in ion levels between the cohorts and inside the gender. Nineteen patients were prospectively analyzed. The correlation with clinical-radiographic data was also performed. Chromium, cobalt, nickel, and molybdenum concentrations were measured by atomic absorption spectrophotometry.
Chromium and cobalt levels demonstrated a tendency to decrease over time. Such tendency was present only in females. An inverse correlation between chromium, implant size, and Harris hip score was present at short term; it disappeared over time together with the decreased ion levels. The prospective analysis showed that, although metal ion levels remained fairly constant within each patient, there was a relatively large variation between subjects, so mean data in this scenario must be interpreted with caution.
The chronic high exposure should be carefully considered during implant selection, particularly in young subjects, and a stricter monitoring is mandatory.
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Christian WV, Oliver LD, Paustenbach DJ, Kreider ML, Finley BL. Toxicology-based cancer causation analysis of CoCr-containing hip implants: a quantitative assessment of genotoxicity and tumorigenicity studies. J Appl Toxicol 2014; 34:939-67. [DOI: 10.1002/jat.3039] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/23/2014] [Accepted: 05/24/2014] [Indexed: 12/12/2022]
Affiliation(s)
| | - Lindsay D. Oliver
- Cardno ChemRisk; LLC, 4840 Pearl East Circle, Suite 300 West Boulder CO 80301 USA
| | | | - Marisa L. Kreider
- Cardno ChemRisk, LLC; 20 Stanwix St., Suite 505 Pittsburgh PA 15222 USA
| | - Brent L. Finley
- Cardno ChemRisk; LLC, 231 Front St., Suite 201 Brooklyn NY 11201 USA
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Paustenbach DJ, Galbraith DA, Finley BL. Interpreting cobalt blood concentrations in hip implant patients. Clin Toxicol (Phila) 2013; 52:98-112. [DOI: 10.3109/15563650.2013.857024] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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