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Wu T, Guo S, Jiang Y, Shi W, Wang Y, Li T. Ceramic fragmentation after total hip arthroplasty: two case reports and literature review. Front Surg 2024; 11:1357301. [PMID: 38444899 PMCID: PMC10912464 DOI: 10.3389/fsurg.2024.1357301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 02/09/2024] [Indexed: 03/07/2024] Open
Abstract
Background Ceramic fragmentation is a rare but serious complication after total hip arthroplasty (THA). We reviewed the PubMed literature from 1990 to 2023 and found only 31 case reports of ceramic fragmentation after THA. Our case reports help to expand understanding of this rare complication. We shared our surgical experience and identified an ideal material for revision surgery, which can serve as a useful reference for other orthopedic surgeons to perform ceramic fragmentation revision surgery in the future. We also analyzed the possible causes, diagnosis, and treatment opinions of ceramic fragmentation. Case presentation This study presents two cases of ceramic fragmentation after THA. One patient had ceramic head fragmentation 10 years after the primary THA, and one patient had ceramic liner fragmentation 5 years after the primary THA. Both patients presented with pain, and one patient also reported a clicking sound in the hip. The two patients described here had BMIs of 23.7 and 23.1, respectively. Both patients' ceramic fragmentation were due to aseptic loosening, not periprosthetic joint infections, as confirmed by negative microbiological cultures. Radiographic examinations of both patients revealed radio-opaque wear debris around the hip joint prostheses and we describe the surgical protocols and intraoperative findings in both cases in detail. Conclusion Our cases and the literature suggest that ceramic fragmentation can occur at any time after THA. The most immediate symptoms are pain and noise, but some patients may be asymptomatic. Ceramic on polyethylene bearings is recommended for revision surgery whenever possible; metal bearings should be avoided.
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Affiliation(s)
- Tingyu Wu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Sijia Guo
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yaping Jiang
- Department of Oral Implantology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Weipeng Shi
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yingzhen Wang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tao Li
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Glaß H, Jonitz-Heincke A, Petters J, Lukas J, Bader R, Hermann A. Corrosion Products from Metallic Implants Induce ROS and Cell Death in Human Motoneurons In Vitro. J Funct Biomater 2023; 14:392. [PMID: 37623637 PMCID: PMC10455184 DOI: 10.3390/jfb14080392] [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: 06/20/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/26/2023] Open
Abstract
Due to advances in surgical procedures and the biocompatibility of materials used in total joint replacement, more and younger patients are undergoing these procedures. Although state-of-the-art joint replacements can last 20 years or longer, wear and corrosion is still a major risk for implant failure, and patients with these implants are exposed for longer to these corrosive products. It is therefore important to investigate the potential effects on the whole organism. Released nanoparticles and ions derived from commonly used metal implants consist, among others, of cobalt, nickel, and chromium. The effect of these metallic products in the process of osteolysis and aseptic implant loosening has already been studied; however, the systemic effect on other cell types, including neurons, remains elusive. To this end, we used human iPSC-derived motoneurons to investigate the effects of metal ions on human neurons. We treated human motoneurons with ion concentrations regularly found in patients, stained them with MitoSOX and propidium iodide, and analyzed them with fluorescence-assisted cell sorting (FACS). We found that upon treatment human motoneurons suffered from the formation of ROS and subsequently died. These effects were most prominent in motoneurons treated with 500 μM of cobalt or nickel, in which we observed significant cell death, whereas chromium showed fewer ROS and no apparent impairment of motoneurons. Our results show that the wear and corrosive products of metal implants at concentrations readily available in peri-implant tissues induced ROS and subsequently cell death in an iPSC-derived motoneuron cell model. We therefore conclude that monitoring of neuronal impairment is important in patients undergoing total joint replacement.
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Affiliation(s)
- Hannes Glaß
- Translational Neurodegeneration Section “Albrecht Kossel”, Department of Neurology, University Medical Center Rostock, University of Rostock, 18147 Rostock, Germany; (H.G.)
| | - Anika Jonitz-Heincke
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopedics, University Medical Center Rostock, University of Rostock, 18057 Rostock, Germany
| | - Janine Petters
- Translational Neurodegeneration Section “Albrecht Kossel”, Department of Neurology, University Medical Center Rostock, University of Rostock, 18147 Rostock, Germany; (H.G.)
| | - Jan Lukas
- Translational Neurodegeneration Section “Albrecht Kossel”, Department of Neurology, University Medical Center Rostock, University of Rostock, 18147 Rostock, Germany; (H.G.)
- Center for Transdisciplinary Neurosciences Rostock (CTNR), University Medical Center Rostock, University of Rostock, 18147 Rostock, Germany
| | - Rainer Bader
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopedics, University Medical Center Rostock, University of Rostock, 18057 Rostock, Germany
| | - Andreas Hermann
- Translational Neurodegeneration Section “Albrecht Kossel”, Department of Neurology, University Medical Center Rostock, University of Rostock, 18147 Rostock, Germany; (H.G.)
- Center for Transdisciplinary Neurosciences Rostock (CTNR), University Medical Center Rostock, University of Rostock, 18147 Rostock, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Rostock/Greifswald, 18147 Rostock, Germany
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Crutsen JRW, Koper MC, Jelsma J, Heymans M, Heyligers IC, Grimm B, Mathijssen NMC, Schotanus MGM. Prosthetic hip-associated cobalt toxicity: a systematic review of case series and case reports. EFORT Open Rev 2022; 7:188-199. [PMID: 35298414 PMCID: PMC8965198 DOI: 10.1530/eor-21-0098] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Prosthetic hip-associated cobalt toxicity (PHACT) is caused by elevated blood cobalt concentrations after hip arthroplasty. The aim of this study is to determine which symptoms are reported most frequently and in what type of bearing. We also try to determine the blood level of cobalt concentrations associated with toxicological symptoms. A systematic review was conducted on the 10th of July according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A methodological quality assessment (risk of bias (RoB)) was performed. Primary outcomes were the reported symptoms of cobalt toxicity and the level of cobalt concentrations in blood. These levels were associated with toxicological symptoms. A total of 7645 references were found of which 67 relevant reports describing 79 patients. The two most used bearings in which PHACT was described were metal-on-metal (MoM) bearings (38 cases) and revised (fractured) ceramic-on-ceramic (CoC) bearings where the former ceramic head was replaced by a metal head (32 cases). Of all reported symptoms, most were seen in the neurological system, of which 24% were in the sensory system and 19.3% were in central/peripheral system, followed by the cardiovascular (22.1%) system. The mean cobalt concentration for MoM-bearings was 123.7 ± 96.8 ppb and 1078.2 ± 1267.5 ppb for the revised fractured CoC-bearings. We recommend not to use a metal-based articulation in the revision of a fractured CoC bearing and suggest close follow-up with yearly blood cobalt concentration controls in patients with a MoM bearing or a revised fractured CoC bearing. Level of Evidence: Level V, systematic review.
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Affiliation(s)
- J R W Crutsen
- Department of Orthopaedic Surgery, VieCuri Medical Center, Venlo, the Netherlands
| | - M C Koper
- Department of Orthopaedic Surgery, Reinier HAGA Orthopaedic Center, Zoetermeer, the Netherlands
| | - J Jelsma
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, the Netherlands
| | - M Heymans
- Zuyderland Academy, Centre of Knowledge and Information (KIC), Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| | - I C Heyligers
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, the Netherlands
- School of Health Professions Education (SHE), Maastricht University, Maastricht, the Netherlands
| | - B Grimm
- Luxembourg Institute Health, Human Motion, Orthopaedics, Sports Medicine, Digital Methods (HOSD), Luxembourg, Luxembourg
| | - N M C Mathijssen
- Department of Orthopaedic Surgery, Reinier HAGA Orthopaedic Center, Zoetermeer, the Netherlands
| | - M G M Schotanus
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, the Netherlands
- School of Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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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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Jonitz-Heincke A, Sellin ML, Seyfarth A, Peters K, Mueller-Hilke B, Fiedler T, Bader R, Klinder A. Analysis of Cellular Activity Short-Term Exposure to Cobalt and Chromium Ions in Mature Human Osteoblasts. MATERIALS 2019; 12:ma12172771. [PMID: 31466377 PMCID: PMC6747798 DOI: 10.3390/ma12172771] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/23/2019] [Accepted: 08/26/2019] [Indexed: 01/19/2023]
Abstract
In aseptic loosening of endoprosthetic implants, metal particles, as well as their corrosion products, have been shown to elicit a biological response. Due to different metal alloy components, the response may vary depending on the nature of the released corrosion product. Our study aimed to compare the biological effects of different ions released from metal alloys. In order to mimic the corrosion products, different metal salts (CoCl2, NiCl2 and CrCl3 × 6H2O) were dissolved and allowed to equilibrate. Human osteoblasts were incubated with concentrations of 10 µM to 500 µM metal salt solutions under cell culture conditions, whereas untreated cells served as negative controls. Cells exposed to CoCr28Mo6 particles served as positive controls. The cell activity and expression of osteogenic differentiation and pro-osteolytic mediators were determined. Osteoblastic activity revealed concentration- and material-dependent influences. Collagen 1 synthesis was reduced after treatment with Co(2+) and Ni(2+). Additionally, exposure to these ions (500 µM) resulted in significantly reduced OPG protein synthesis, whereas RANKL as well as IL-6 and IL-8 secretion were increased. TLR4 mRNA was significantly induced by Co(2+) and CoCr28Mo6 particles. The results demonstrate the pro-osteolytic capacity of metal ions in osteoblasts. Compared to CoCr28Mo6 particles, the results indicated that metal ions intervene much earlier in inflammatory processes.
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Affiliation(s)
- Anika Jonitz-Heincke
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopedics, Rostock University Medical Centre, Doberaner Strasse 142, 18057 Rostock, Germany.
| | - Marie-Luise Sellin
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopedics, Rostock University Medical Centre, Doberaner Strasse 142, 18057 Rostock, Germany
| | - Anika Seyfarth
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopedics, Rostock University Medical Centre, Doberaner Strasse 142, 18057 Rostock, Germany
| | - Kirsten Peters
- Department of Cell Biology, Rostock University Medical Center, Schillingallee 69, 18057 Rostock, Germany
| | - Brigitte Mueller-Hilke
- Institute for Immunology, Rostock University Medical Center, Schillingallee 70, 18057 Rostock, Germany
| | - Tomas Fiedler
- Institute for Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, Schillingallee 70, 18057 Rostock, Germany
| | - Rainer Bader
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopedics, Rostock University Medical Centre, Doberaner Strasse 142, 18057 Rostock, Germany
| | - Annett Klinder
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopedics, Rostock University Medical Centre, Doberaner Strasse 142, 18057 Rostock, Germany
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Fatal Cobalt Toxicity after a Non-Metal-on-Metal Total Hip Arthroplasty. Case Rep Orthop 2017; 2017:9123684. [PMID: 28929003 PMCID: PMC5591987 DOI: 10.1155/2017/9123684] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/30/2017] [Indexed: 12/02/2022] Open
Abstract
This case illustrates the potential for systemic cobalt toxicity in non-metal-on-metal bearings and its potentially devastating consequences. We present a 71-year-old male with grinding sensations in his right hip following ceramic-on-ceramic total hip arthroplasty (THA). After diagnosing a fractured ceramic liner, the hip prosthesis was revised into a metal-on-polyethylene bearing. At one year postoperatively, X-rays and MARS-MRI showed a fixed reversed hybrid THA, with periarticular densities, flattening of the femoral head component, and a pattern of periarticular metal wear debris and pseudotumor formation. Before revision could take place, the patient was admitted with the clinical picture of systemic cobalt toxicity, supported by excessively high serum cobalt and chromium levels, and ultimately died. At autopsy dilated cardiomyopathy as cause of death was hypothesized. A third body wear reaction between ceramic remnants and the metal femoral head very likely led to excessive metal wear, which contributed systemic cobalt toxicity leading to neurotoxicity and heart failure. This case emphasizes that fractured ceramic-on-ceramic bearings should be revised to ceramic-on-ceramic or ceramic-on-polyethylene bearings, but not to metal-on-polyethylene bearings. We aim to increase awareness among orthopedic surgeons for clinical clues for systemic cobalt intoxication, even when there is no metal-on-metal bearing surface.
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