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Brüggemann A, Hailer NP. Concentrations of Cobalt, Chromium and Titanium and Immunological Changes after Primary Total Knee Arthroplasty-A Cohort Study with an 18-Year Follow-Up. J Clin Med 2024; 13:951. [PMID: 38398263 PMCID: PMC10889704 DOI: 10.3390/jcm13040951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Total knee arthroplasty (TKA) generates elevated metal ion concentrations, but long-term changes in the concentrations of cobalt (Co), chromium (Cr) and titanium (Ti) after primary TKA and potential subsequent immune system activation-not limited to the joint but systemically-are not known. Patients and Methods: We conducted a cohort study on 26 patients with TKA (19 women; 16 with metal-backed and 10 with all-polyethylene tibial components) 18.3 years (min. 16.7, max. 20.5) after index TKA. A total of 69% of patients additionally underwent subsequent arthroplasty of the contralateral knee or either hip after the index surgery. Blood samples were analysed by inductively coupled plasma-mass spectrometry, and leukocytes were characterised by flow cytometry. Patients were clinically assessed using the Knee Society score and by plain radiography of the knee. Results: The median metal ion concentrations were 0.7 (0.1-13.0) µg/L for Co, 0.9 (0.4-5.0) µg/L for Cr, and 1.0 (0.2-13.0) µg/L for Ti. There was no relevant difference in systemic metal ion concentrations between patients exposed to single and multiple arthroplasties. The absolute count and proportion of CD3+CD4+CD8+ T cells was inversely correlated with both Co (rho -0.55, p = 0.003) and Cr concentrations (rho -0.59, p = 0.001). Conclusions: Between the first and second decades after primary TKA, in most patients, the concentrations of Co, Cr and Ti in blood samples were below the thresholds that are considered alarming. The negative correlation of Co and Cr concentrations with a subset of lymphocytes that commonly increases during immune activation is reassuring. This represents a worst-case scenario, underscoring that the investigated metal ions remain within reasonable ranges, even after additional hardware exposure.
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Affiliation(s)
| | - Nils P. Hailer
- Orthopaedics—Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden;
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Systemic Metal Ion Concentrations in Patients With Hip and Knee Megaprostheses: A Prospective Cohort Study. Arthroplast Today 2022; 18:191-201.e1. [PMID: 36561551 PMCID: PMC9764025 DOI: 10.1016/j.artd.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/03/2022] [Accepted: 08/09/2022] [Indexed: 12/13/2022] Open
Abstract
Background Local tissue and serum metal ions have been shown to be elevated in some metal-on-metal and metal-on-polyethylene joint replacements. Local elevations have been linked to adverse local tissue reactions in some patients, and systemic elevation has been less commonly implicated cardiac and neurologic issues. Using a prospective study design, we aimed to identify the changes in serum metal ion levels after hip or knee megaprosthesis reconstruction. Furthermore, we will evaluate the occurrence of adverse effects and complications, possibly linked to metal ion elevation. Methods Fourteen consecutive patients receiving a Modular Universal Tumor Revision System megaprosthesis were enrolled. Blood samples were collected preoperatively and postoperatively to determine the serum ion concentrations of aluminum, chromium, cobalt, and silver. To evaluate the safety of the megaprostheses and the subsequently possible related (elevated) serum metal ion concentrations, all adverse effects and complications were registered until last outpatient clinic visit at the time of this study. Results Compared to the preoperative median serum concentrations, the postoperative median serum concentrations of chromium, silver, and cobalt increased 11-fold, 62-fold, and 64-fold, respectively. The median serum concentration of aluminum increased with 16%. Elevations were primarily noted in patients with knee prostheses. Eight patients had no adverse effects or complications during the period between preoperative and postoperative blood sampling. One adverse effect directly related to the serum metal ion concentrations, namely argyria, was observed. Conclusions This study documents significantly elevated concentrations of the metal ions, but only one adverse effect directly related to the metal ion concentrations was observed. Future studies are needed to further assess the impact of elevated metal ion levels after megaprostheses, specifically knee implants, which are metal-on-metal.
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Manescu (Paltanea) V, Antoniac I, Antoniac A, Paltanea G, Miculescu M, Bita AI, Laptoiu S, Niculescu M, Stere A, Paun C, Cristea MB. Failure Analysis of Ultra-High Molecular Weight Polyethylene Tibial Insert in Total Knee Arthroplasty. MATERIALS (BASEL, SWITZERLAND) 2022; 15:7102. [PMID: 36295170 PMCID: PMC9605650 DOI: 10.3390/ma15207102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/09/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
Knee osteoarthritis is treated based on total knee arthroplasty (TKA) interventions. The most frequent failure cause identified in surgical practice is due to wear and oxidation processes of the prothesis' tibial insert. This component is usually manufactured from ultra-high molecular weight polyethylene (UHMWPE). To estimate the clinical complications related to a specific prosthesis design, we investigated four UHMWPE tibial inserts retrieved from patients from Clinical Hospital Colentina, Bucharest, Romania. For the initial analysis of the polyethylene degradation modes, macrophotography was chosen. A light stereomicroscope was used to estimate the structural performance and the implant surface degradation. Scanning electron microscopy confirmed the optical results and fulfilled the computation of the Hood index. The oxidation process in UHMWPE was analyzed based on Fourier-transform infrared spectroscopy (FTIR). The crystallinity degree and the oxidation index were computed in good agreement with the existing standards. Mechanical characterization was conducted based on the small punch test. The elastic modulus, initial peak load, ultimate load, and ultimate displacement were estimated. Based on the aforementioned experimental tests, a variation between 9 and 32 was found in the case of the Hood score. The oxidation index has a value of 1.33 for the reference sample and a maximum of 9.78 for a retrieved sample.
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Affiliation(s)
- Veronica Manescu (Paltanea)
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
- Faculty of Electrical Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Iulian Antoniac
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
- Academy of Romanian Scientists, 54 Splaiul Independentei, 050094 Bucharest, Romania
| | - Aurora Antoniac
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Gheorghe Paltanea
- Faculty of Electrical Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Marian Miculescu
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Ana-Iulia Bita
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Stefan Laptoiu
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Marius Niculescu
- Faculty of Medicine, Titu Maiorescu University, 67A Gheorghe Petrascu Street, 031593 Bucharest, Romania
- Department of Orthopedics and Trauma I, Colentina Clinical Hospital, 19-21 Soseaua Stefan cel Mare, 020125 Bucharest, Romania
| | - Alexandru Stere
- Medical Ortovit Ltd., 8 Miron Costin Street, 011098 Bucharest, Romania
| | - Costel Paun
- Faculty of Electrical Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
- National Institute for Research and Development in Microtechnologies IMT-Bucharest, 126A Erou Iancu Nicolae Street, 077190 Bucharest, Romania
| | - Mihai Bogdan Cristea
- Department of Morphological Sciences, Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania
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Tarity TD, Vigdorchik JM, Westrich GH, Gonzalez Della Valle A, Cerrito P, Baral EC, Bromage TG, Bauer TW. Adaptive Immune Response Associated with a Zirconium-Containing, Cemented, Total Knee Arthroplasty: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00092. [PMID: 34449449 DOI: 10.2106/jbjs.cc.21.00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
CASE A 69-year-old woman underwent revision total knee arthroplasty for patellar component aseptic loosening. The periprosthetic tissue demonstrated histologic features of an adaptive immune response (aseptic lymphocyte-dominant vasculitis-associated lesion [ALVAL]). No particles of corrosion debris were identified. The inflammation seemed to be associated with zirconium oxide (ZrO2) particles added as a bone cement radio-opacifier. CONCLUSION The factors responsible for the adaptive immune response cannot be determined with certainty; however, this is the first reported case of ALVAL associated with ZrO2-containing bone cement. Previous reports describing ALVAL around failed total knee prostheses have not included observations about the type of contrast material added to cement.
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Affiliation(s)
- T David Tarity
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, New York
| | - Jonathan M Vigdorchik
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, New York
| | - Geoffrey H Westrich
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, New York
| | | | - Paola Cerrito
- Departments of Anthropology and Molecular Pathobiology, New York University College of Dentistry, New York, New York
| | - Elexis C Baral
- Department of Biomedical Engineering, Hospital for Special Surgery, New York, New York
| | - Timothy G Bromage
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, New York
| | - Thomas W Bauer
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, New York
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Schneiderman BA, Yang S, Dipane M, Lu C, McPherson EJ, Schmalzried TP. Periprosthetic Tissue Reaction Independent of LTT Result and Implanted Materials in Total Knee Arthroplasty. J Arthroplasty 2021; 36:2480-2485. [PMID: 33714633 DOI: 10.1016/j.arth.2021.02.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND An allergic reaction may rarely cause a painful or stiff total knee arthroplasty (TKA). However, no consensus diagnostic criteria for TKA immune failure exist. Lymphocyte transformation testing (LTT) measures immune sensitivity to various materials, but its role in diagnosing an allergic reaction to a TKA has not been established. This study compares TKA periprosthetic tissues in a) LTT-positive versus -negative patients and b) patients with conventional CoCrNi versus hypoallergenic implants. METHODS Periprosthetic tissues from 26 revision cases of well-fixed, aseptic, but painful or stiff TKAs were analyzed. Twelve patients LTT positive for nickel (Ni) were matched as a cohort to 6 LTT-negative patients. In 4 patients LTT positive for Ni, tissue from first revision of CoCrNi implants was compared with tissue from subsequent revision of hypoallergenic implants. Histology was evaluated using the aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) score. RESULTS No correlation was found between LTT and any ALVAL score component. The mean total ALVAL score was 3.8 ± 1.5 for LTT-negative patients and 3.3 ± 1.2 for LTT-positive patients (P = .44). The mean total ALVAL score at revision of CoCrNi implants was 3.0 ± 1.8 compared with 5.8 ± 0.5 at rerevision of hypoallergenic implants (P = .053). CONCLUSION Periprosthetic TKA tissue reactions were indistinguishable between LTT-positive and -negative patients. LTT does not predict the periprosthetic tissue response. ALVAL scores of hypoallergenic revision implant tissue trended higher than primary CoCrNi implant tissue. A positive LTT may not indicate that a periprosthetic immune reaction is the cause of pain and stiffness after TKA. LEVEL OF EVIDENCE 3, retrospective cohort study.
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Affiliation(s)
| | - Steven Yang
- Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Torrance CA
| | - Matthew Dipane
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Conrad Lu
- Joint Replacement Institute at St. Vincent Medical Center, Los Angeles CA
| | - Edward J McPherson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Thomas P Schmalzried
- Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Torrance CA; Joint Replacement Institute at St. Vincent Medical Center, Los Angeles CA
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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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