Severe metallosis following catastrophic failure of total shoulder arthroplasty - a case report

Metallosis is an unusual but consequential complication arising from orthopedic hardware implantation, characterized by the deposition of metallic particles in the periprosthetic soft tissues. The incidence of metallosis associated with shoulder arthroplasties is exceptionally rare since the shoulder is not a weight-bearing joint, making it less susceptible to mechanical wear and, consequently, to conditions like particle disease and metallosis. Nevertheless, anomalous metal-on-metal interactions can develop in total shoulder arthroplasties if the polyethylene component fails due to wear, fracture, or dissociation. If left unaddressed, metallosis can incite an adverse immune-mediated local tissue response, culminating in joint destruction and adjacent soft tissues and muscle necrosis. In this case report, the diagnosis of metallosis was made in a patient with an anatomic total shoulder arthroplasty using a state-of-the-art photon counting detector CT supplemented by post-processing metal artifact reduction algorithms. This advanced imaging approach was effective in discerning the source of implant failure and in identifying manifestations of severe metallosis including osteolysis and pseudotumor formation. Advanced imaging methods can accurately characterize the severity and extent of metallosis, thereby helping guide surgical planning to mitigate serious complications associated with this condition.

Adverse Local Tissue Reaction Secondary to Corrosion at Multiple Junctions in a Modular, Segmental, Distal Femoral Replacement

While adverse local tissue reactions are well described in the total hip arthroplasty literature, there have only been case reports and case series in the total knee arthroplasty literature. There have been no cases described in the setting of a distal femoral replacement. In this case, we describe a 69-year-old female with a complex history of left knee revision arthroplasty with a distal femoral and proximal tibial replacement who presented with left knee pain and was found to have extensive adverse local tissue reaction with corrosion at the femoral stem-extension piece junction and the extension piece-distal femoral component junction. The femoral taper was then manually cleaned and modular components replaced. Corrosion at the stem-distal femoral component junction can result in adverse local tissue reaction in patients with distal femoral replacements. It is important to consider this diagnosis when evaluating patients with knee pain following distal femoral replacement.

Wear debris in metal-on-metal bearings and modular junctions : What have we learned from the last decades?

Metal-on-metal (MoM) bearing hip arthroplasty saw increasing utilization and peaked in the 1990s and early 2000s. Although the linear and volumetric wear rate for a MoM bearings was lower than its polyethylene counterpart, metal ion particles were found to be approximately 10 × smaller and 500 × higher in quantity compared to polyethylene wear debris. Research into these articulations have demonstrated their relationship to the formation of lymphocyte-mediated adverse local tissue reactions. The work-up for metal particle-associated conditions (metallosis) includes a thorough patient history and physical examination, blood laboratory studies for metal ion concentrations, and advanced imaging studies including magnetic resonance imaging (MRI). The treatment of metallosis and adverse local tissue reactions ranges from close serial observation to extensive debridement and full revision of arthroplasty components, when indicated.

No difference in whole-blood metal ions between 32-mm and 36- to 44-mm femoral heads in metal-on-polyethylene total hip arthroplasty: a 2-year report from a randomised control trial

AIM

To investigate the effect of femoral head size on blood metal-ion levels caused by taper corrosion in metal-on-polyethylene total hip arthroplasty, comparing 36- to 44-mm heads with 32-mm heads.

METHODS

In a randomised, controlled, single-blinded trial, 96 patients were allocated to receive either a 32-mm metal head or the largest possible metal head (36-44 mm) that could be accommodated in the thinnest available vitamin E, cross-linked polyethylene insert. Blood metal ion levels were collected at 1- and 2-year follow-ups.

RESULTS

At 1-year, metal-ion levels did not differ between the groups. The median (interquartile range) blood-ion levels for the 32-mm versus the 36- to 44-mm group were 0.11 µg/L (0.08-0.15) versus 0.12 µg/L (0.08-0.22), p = 0.546, for cobalt, 0.50 µg/L (0.50-0.59) versus 0.50 µg/L (0.50-1.20), p = 0.059, for chromium and 1.58 µg/L (1.38-2.05) versus 1.48 µg/L (1.14-1.87), p = 0.385, for titanium. At 2 years, there was no difference either and the corresponding values were 0.15 µg/L (0.12-0.24) versus 0.18 µg/L (0.12-0.28), p = 0.682 for cobalt, 0.50 µg/L (0.50-0.50) versus 0.50 µg/L (0.50-0.57), p = 0.554, for chromium and 1.54 µg/L (1.16-1.87) versus 1.42 µg/L (1.01-1.72), p = 0.207 for titanium.

CONCLUSIONS

The use of the largest possible metal head (36-44 mm) compared to a 32-mm head in metal-on-polyethylene bearings does not appear to elevate blood metal-ion levels up to 2 years postoperatively. As taper corrosion is probably time-dependent, longer-term reports are needed to evaluate the association between large metal heads and blood metal ion levels.Trial registration: ClinicalTrials.gov (reg. ID NCT0231 6704).

Do polyethylene wear particles affect the development of pseudotumor in total hip arthroplasty? A minimum 15-year follow-up

BACKGROUND

Adverse local tissue reactions have been problematic as an implant-related complication in total hip arthroplasty (THA). Despite the absence of significant metal wear and corrosion, granulomatous pseudotumor has been reported to be caused by polyethylene wear. We performed a long-term follow-up study investigating the relationship between polyethylene wear and pseudotumor formation in THA.

METHODS

This study included 57 patients (64 hips) that underwent primary THA with metal-on-polyethylene or ceramic-on-polyethylene bearing over a minimum follow-up of 15 years. They were stratified into pseudotumor and non-pseudotumor groups and their linear wear rates of polyethylene liner and serum cobalt (Co) and chromium (Cr) ion levels were compared. Pseudotumor was diagnosed on metal artifact reduction sequence-MRI according to its composition and wall thickness using the Hauptfleisch classification.

RESULTS

The incidence of pseudotumor was 34% (22/64 hips) at the mean follow-up of 16.9 years. Metal ion levels did not differ between the pseudotumor and non-pseudotumor groups, and none of the patients exceeded the Co/Cr ratio of 2.0 μg/L. Moreover, the wear rate in the pseudotumor group was 1.8 times greater than in the non-pseudotumor group (0.14 vs. 0.08 mm/year, P < 0.001). According to an analysis of the receiver operating characteristic curves, the cutoff level of the wear rate to discriminate between pseudotumor and non-pseudotumor patients at 15 years was 0.11 mm/year (area under the curve = 91%; sensitivity = 95%; specificity = 78%; accuracy = 87%).

CONCLUSIONS

Our results might provide new insights into excessive polyethylene wear potentially leading to the future development of both pseudotumor and osteolysis. Further studies are needed to clarify the direct relationship between polyethylene wear and pseudotumor and the mutual effects of osteolysis and pseudotumor in particle reactions.

High risk of elevated metal concentrations with 9/10-mm stem trunnions and highly cross-linked polyethylene grafted with poly(2-methacryloyloxyethyl phosphorylcholine) in total hip arthroplasty

BACKGROUND

The risks of metal release due to fretting and corrosion at the head-neck junction and consequent adverse local tissue reaction (ALTR) have concerns in metal-on-polyethylene (MoP) total hip arthroplasty (THA). Although trunnions have become thinner in diameter to increase the range of motion, it has remained unclear whether this change affects metal release and ALTR in vivo. This study aimed to investigate serum metal concentrations and the prevalence of ALTR in MoP THA with a 9/10-mm stem trunnion.

PATIENTS AND METHODS

A consecutive series of 37 hips that underwent THA using MoP grafted with poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) with a 9/10-mm trunnion stem were retrospectively reviewed. Serum metal levels were assessed and compared with those in MoP THA with a 10/12-mm trunnion stem. ALTR was diagnosed with serum metal levels and cross-sectional images. The factors associated with serum metal levels were also assessed.

RESULTS

The median serum cobalt and chromium levels were 1.5 μg/L and 1.0 μg/L in the 9/10-mm group and 0.2 μg/L and 0.4 μg/L in the 10/12-mm group, respectively. ALTR was found in 5 hips of 3 patients. Revision surgery was performed in 4 hips, and all stem trunnions and femoral heads showed severe corrosion. Postoperative walking ability was associated with serum metal levels.

CONCLUSION

It was found that a 9/10-mm stem trunnion with MoP grafted with PMPC had high risks of metal release in primary THA. Careful follow-up and cross-sectional imaging are needed to detect ALTR for early revision.

Adverse reaction to metal debris with accompanying gout and amyloid deposits in hip arthroplasty

Adverse reaction to metal debris (ARMD) is a known complication of metal-on-metal hip arthroplasty. There has been one previously reported case of ARMD with concomitant gout in the setting of a hip arthroplasty. We report a case of ARMD with accompanying monosodium urate crystals as well as amyloid deposition in the hip of a patient who had undergone a metal-on-metal hip arthroplasty. This is the only published case to date of these 3 conditions co-existing, although it is possible that the incidence is higher since these require special diagnostic tests that are not routinely performed. It is postulated that these entities are biochemically associated with each other rather than being purely coincidental.

Outcome of revision surgery for adverse local tissue reactions in patients with recalled total hip arthroplasty

INTRODUCTION

Recalls of total hip arthroplasty (THA) implants, including metal-on-metal (MoM) THA and dual taper stems, due to increased risk of adverse local tissue reaction (ALTR), represent a challenge for both surgeons and patients. This study aims to analyze the revision surgery outcomes for ALTR in patients with recalled THA implants.

METHODS

A total of 118 consecutive patients who underwent revision surgery due to ALTR with recalled THA were analyzed. Sub-group analysis was performed for recalled MoM THAs, head-neck modular stems, and dual taper neck-stems.

RESULTS

At a mean follow-up of 6.6 years, the complication and reoperation rates of the recalled THAs were 32.2% and 25.4% respectively. The most common post-revision complication was dislocation (16%). Revision of modular taper corrosion THA and high-grade intraoperative tissue damage were risk factors associated with post-revision complications.

CONCLUSION

This study reports high complication and reoperation rates of recalled THAs at mid-term follow-up. The high revision surgery complication rates in both groups suggest the importance of a systematic evaluation of all THA patients with at-risk implants.

LEVEL OF EVIDENCE

Level III, case control retrospective analysis.

Long-term survivorship of an exchangeable-neck hip prosthesis with a Ti-alloy/Ti-alloy neck-stem junction

INTRODUCTION

Breakage of exchangeable-neck (EN) and adverse local tissue reactions (ALTRs) to neck-stem junction (NSJ) damage products are responsible for increasing the revision rate of EN hip prostheses. We investigated the survivorship of an EN hip prosthesis including a NSJ with both components made of titanium alloy (Ti-alloy/Ti-alloy) to assess whether, and to what extent, EN breakage and NSJ damage affected implant survivorship.

MATERIALS AND METHODS

Using data from a hip replacement registry, we determined survivorship of 2857 EN prostheses. Long-offset configurations of head and EN were implanted in heavy (> 90 kg) patients only in 23 hips. We investigated under which conditions EN breakages or ALTRs occurred. We also measured titanium (Ti) and vanadium (V) blood concentrations in 24 patients with a unilateral well-working prosthesis.

RESULTS

The 17-year survival rates for any reason and aseptic loosening of any component were 88.9% (95%CI 87.5-90.1; 857 hips at risk) and 96.9% (95%CI 96.0-97.6), respectively. There were two cases of EN breakage and one case of ALTR (metallosis), due to rim-neck impingement, out of 276 revisions. After an average period of 9.8 years (range 7.8-12.8 years), the maximum Ti and V blood concentrations in patients with a well-working prosthesis were 5.0 µg/l and 0.16 µg/l, respectively.

CONCLUSION

The present incidence of EN breakage or ALTR is lower than those reported in other studies evaluating EN hip prosthesis survivorship. This study suggests that (i) the risk of EN breakage is reduced by limiting the use of long-offset configurations in heavy patients and (ii) Ti-alloy/Ti-alloy NSJ damage products do not promote ALTR nor significantly alter the rate of implant loosening. Since design decisions and implant configuration determine the NSJ strength, the NSJ strength in working conditions must be thoroughly investigated to proper define the clinical indications for any EN design.

Adverse Local Tissue Reaction Associated With Ceramic-On-Metal Bearing Surface in Primary Total Hip Arthroplasty: Report of Two Cases

Total hip arthroplasty (THA) is one of the most common and successful surgical procedures worldwide. At the same time, it is constantly evolving, and as a consequence, advances in implant technology have led to significant improvements in the different materials of the acetabular and femoral components. The selection of bearing surfaces and their tribology are critical to achieving a successful outcome. Pseudotumors are important, and usually misdiagnosed, complications associated with hard bearing surfaces such as metal-on-metal couples. They belong to a group of reactions called adverse local tissue reaction, which can occur in the vicinity of any THA. We present 2 cases of adverse local tissue reaction associated with the use of ceramic-on-metal bearings surfaces in 2 primary THAs that were treated with modular component exchange during single-stage revision surgery.

Level of Evidence

IV.

The incidence of adverse local tissue reaction due to head taper corrosion after total hip arthroplasty using V40 taper and 36 mm CoCr head

AIMS

Head-taper corrosion is a cause of failure in total hip arthroplasty (THA). Recent reports have described an increasing number of V40 taper failures with adverse local tissue reaction (ALTR). However, the real incidence of V40 taper damage and its cause remain unknown. The aim of this study was to evaluate the long-term incidence of ALTR in a consecutive series of THAs using a V40 taper and identify potentially related factors.

METHODS

Between January 2006 and June 2007, a total of 121 patients underwent THA using either an uncemented (Accolade I, made of Ti₁₂Mo₆Zr₂Fe; Stryker, USA) or a cemented (ABG II, made of cobalt-chrome-molybdenum (CoCrMo); Stryker) femoral component, both with a V40 taper (Stryker). Uncemented acetabular components (Trident; Stryker) with crosslinked polyethylene liners and CoCr femoral heads of 36 mm diameter were used in all patients. At a mean folllow-up of 10.8 years (SD 1.1), 94 patients (79%) were eligible for follow-up (six patients had already undergone a revision, 15 had died, and six were lost to follow-up). A total of 85 THAs in 80 patients (mean age 61 years (24 to 75); 47 (56%) were female) underwent clinical and radiological evaluation, including the measurement of whole blood levels of cobalt and chrome. Metal artifact reduction sequence MRI scans of the hip were performed in 71 patients.

RESULTS

A total of 20 ALTRs were identified on MRI, with an incidence of 26%. Patients with ALTR had significantly higher median Co levels compared with those without ALTR (2.96 μg/l (interquartile range (IQR) 1.35 to 4.98) vs 1.44 μg/l (IQR 0.79 to 2.5); p = 0.019). Radiological evidence of osteolysis was also significantly associated with ALTR (p = 0.014). Median Cr levels were not significantly higher in those with ALTR compared with those without one (0.97 μg/l (IQR 0.72 to 1.9) v 0.67 μg/l (IQR 0.5 to 1.19; p = 0.080). BMI, sex, age, type of femoral component, head length, the inclination of the acetabular component, and heterotopic ossification formation showed no significant relationship with ALTR.

CONCLUSION

Due to the high incidence of local ALTR in our cohort after more than ten years postoperatively, we recommend regular follow-up investigation even in asymptomatic patients with V40 taper and metal heads. As cobalt levels correlate with ALTR occurrence, routine metal ion screening and consecutive MRI investigation upon elevation could be discussed. Cite this article: Bone Joint J 2022;104-B(7):852-858.

Impact of perivascular lymphocytic infiltration in aseptic total knee revision

AIMS

A limited number of investigations with conflicting results have described perivascular lymphocytic infiltration (PVLI) in the setting of total knee arthroplasty (TKA). The purpose of this study was to determine if PVLI found in TKAs at the time of aseptic revision surgery was associated with worse clinical outcomes and survivorship.

METHODS

A retrospective review was conducted on 617 patients who underwent aseptic TKA revision who had histological analysis for PVLI at the time of surgery. Clinical and radiological data were obtained pre- and postoperatively, six weeks postoperatively, and then every year thereafter.

RESULTS

Within this cohort, 118 patients (19.1%) were found to have PVLI on histological analysis. Re-revision was performed on 83 patients (13.4%) with no significant differences in all-cause or aseptic revisions between groups. A higher incidence of PVLI was noted in female patients (p = 0.037). There was no significant difference in improvement in the range of motion (p = 0.536), or improvement of KSC (p = 0.66), KSP (p = 0.61), or KSF (p = 0.3) clinical outcome scores between PVLI and no PVLI sub-groups. There was a higher incidence of a preoperative diagnosis of pain in the PVLI group compared with patients without PVLI (p = 0.002) present.

CONCLUSION

PVLI found on large-scale histological analysis in TKAs at aseptic revision surgery was not associated with worse clinical outcomes or rates of re-revision. Cite this article: Bone Joint J 2021;103-B(6 Supple A):145-149.

Current evidence from a worldwide, multicentre, follow-up study of the recalled Articular Surface Replacement Hip System

INTRODUCTION

Our first aim was to report the longitudinal clinical performance of patients treated with the ASR Hip System, a metal-on-metal (MoM) device, in their mid- to late-term follow-up. Secondly, we sought to report on the reasons and risk factors for mid- to late-term implant failure.

METHODS

A total of 1721 ASR patients (1933 hips) from 16 centres in 6 countries were enrolled to a prospective, post-recall study. The average time to enrollment was 7.4 years from index surgery. Data from 3 follow-up visits over 2 years were analysed. Implant performance, based on ion levels and PROMs, was determined at each clinical visit.

RESULTS

The proportion of those exhibiting good performance decreased over time for hip resurfacing (ASR HRA) and total hip arthroplasty (ASR XL) patients. ASR XL patients were likely to exhibit longitudinal blood metal ion increases regardless of symptom state. ASR HRA patients were more likely to present with and maintain good performance over time, especially males with high general health indicators. 6% of ASR HRA and 14% of ASR XL patients were revised throughout the study period.

DISCUSSION

ASR XL THA patients are likely to exhibit blood metal ion increases without accompanying changes in symptom state, and therefore should be followed with annual blood tests at minimum. While appropriately selected ASR HRA patients were the most likely to exhibit low blood metal ion levels and report no symptoms, we recommend vigilant follow-up of all ASR patients to ensure that worsening clinical outcomes and asymptomatic soft tissue damage are not missed.

Progression of adverse local tissue reaction in ASR metal-on-metal hip arthroplasty: a longitudinal MARS-MRI study at mid- to long-term

BACKGROUND

Despite the large number of studies assessing adverse local tissue reaction (ALTR) in metal-on-metal (MoM) hip implants, there is still a lack of knowledge about the natural progression of ALTR. The aims of this study were to describe the natural course of changes in ALTR at mid- to long-term follow-up for patients treated with metal-on-metal hip arthroplasty and to determine possible risk factors associated with change in ALTR.

METHODS

A total of 158 patients (158 hips), 109 MoM hip resurfacing arthroplasties (HRAs) and 49 MoM total hip arthroplasties (THAs), with 2 clinical follow-ups including MARS-MRIs were included. The mean time from index operation to the first visit was 7.6 years (range 3.4-11.4 years), and the mean time between the 2 visits was 1.0 year (range 0.7-1.6 years).

RESULTS

The proportion of patients with moderate or severe ALTR did not increase significantly between the first and second visit for the MoM HRA group (14.7-15.6%; p = 0.850) or the MoM THA group (32.7-36.7%; p = 0.671). 8 (7.3%) HRA patients and 9 (18.4%) THA patients progressed in ALTR grade. None of the collected clinical variables was sensitive or specific in identifying patients with ALTR progression.

CONCLUSIONS

Although ALTR prevalence was high in our cohort, clinically significant ALTR progression was rare. We were unable to find any predictors associated with ALTR change. This indicates that MARS-MRI remains a valuable tool in the follow-up of patients treated with MoM hip devices in identifying patients who may need revision surgery.

Fatal vascular complication due to metallosis

Metallosis is a well-known complication at the site of total hip and knee arthroplasty. Vascular involvement of this complication is rare and generally results from vascular compression by a mass or pseudotumor. In the present report, we have described a case of lower limb acute arterial ischemia due to arterial injury as a complication of metallosis with a fatal outcome.

Impending Trunnion Failure: An Uncommon Radiographic Presentation of Total Hip Arthroplasty Failure

Trunnionosis is emerging as an early mode of failure in conventional metal-on-polyethylene total hip arthroplasty. It is defined as wear or corrosion at the trunnion, the taper at the femoral head-neck interface. Trunnion wear can result in a variety of negative sequelae and, in severe cases, necessitate revision arthroplasty. We describe a 64-year-old man with a metal-on-polyethylene total hip arthroplasty who presented with a sensation of clunking in the hip. Initial imaging and laboratory studies were inconclusive, and the decision was made to monitor. Two years later, trunnion wear was detected on radiographs, presenting as an abnormal alignment of the femoral neck relative to the femoral head. Several case reports and series describe catastrophic total hip arthroplasty failure due to trunnionosis. However, few describe the radiographic signs of wear at the trunnion before gross failure. This early presentation is important to recognize to minimize patient morbidity and aid surgical planning.

Adverse Local Tissue Reaction due to Acetabular Corrosion in Modular Dual-Mobility Constructs

Dual-mobility (DM) bearings in total hip arthroplasty (THA) have been reported to reduce dislocation rates, especially in high-risk patients, and are being rapidly adopted in primary and revision THAs. However, this technology introduces additional interfaces that have the potential to result in unforeseen complications. We present a series of 3 patients with mechanically assisted crevice corrosion at the acetabular component-metal dual-mobility liner interface. Consequently, we urge judicious use and close clinical observation of this new, effective technology in THA.

15-year follow-up of MoM 36-mm THA: clinical, laboratory, and radiological (CT and MRI) prospective assessment

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.

Initial metal ion levels predict risk of elevation in metal on metal total hip arthroplasty

INTRODUCTION

Screening protocols for asymptomatic patients with metal on metal (MoM) total hip arthroplasty (THA) are evolving. Most surgeons began screening patients around 2010 by obtaining cobalt (Co) and chromium (Cr) metal ion levels. There is currently no data available to guide repeat screening in this familiar clinical scenario. Therefore, the following study evaluated how metal ion levels change after an initial metal ion level in patients with MoM THAs.

MATERIALS AND METHODS

171 consecutive patients (265 hips) underwent primary MoM THA. All patients had at least one Co and Cr ion level draw. 84 patients (136 hips) had 2 ion level draws. Ion levels were divided into elevated levels (⩾4.5 ppb) and normal levels (<4.5 ppb). The probability of an ion level returning elevated after an initial normal level was identified. Additionally, a threshold value was determined that reliably identified every patient that did not subsequently rise above 4.5 ppb.

RESULTS

12 metal ion levels were ⩾4.5 ppb on the first lab draw. On the second draw, all 12 remained ⩾4.5 ppb. Of the 121 hips with initial metal ion levels <4.5 ppb, 5 metal ion levels became ⩾4.5 ppb. Utilising an initial screening cutoff of 3.0 ppb, no patient was identified with a second lab value ⩾4.5 ppb.

DISCUSSION

Initial metal ion levels reliably predicted those that would remain elevated or remain normal with a subsequent metal ion level. An initial metal ion level above 3.0 ppb may represent a cutoff at which further workup is necessary.

Revision of a dual-modular stem in patients with adverse tissue reaction

BACKGROUND

Dual-modular femoral components with exchangeable cobalt-chrome neck segments have had higher than expected failure rates due to corrosion and adverse local tissue reaction (ALTR). Complications, survival rates and early clinical outcomes of revision surgery for the treatment of corrosion and ALTR as a result of these implants are underreported.

METHODS

We identified 44 cases of revision THA for corrosion and ALTR resulting from the same dual modular stem. All revision procedures were performed using a modular tapered fluted titanium stem, ceramic heads and highly cross-linked polyethylene.

RESULTS

Complications included: dislocation, infection, reoperation, and chronic pain. Mean Harris Hip Score was 84 following revision surgery.

CONCLUSIONS

Patients undergoing revision surgery for ALTR related to this prosthesis should be aware of the risk of postoperative dislocation and other complications and the potential long-term risk of some chronic pain.

In vitro effects of macrophages on orthopaedic implant alloys and local release of metallic alloy components

AIMS

This study aimed to determine if macrophages can attach and directly affect the oxide layers of 316L stainless steel, titanium alloy (Ti6Al4V), and cobalt-chromium-molybdenum alloy (CoCrMo) by releasing components of these alloys.

METHODS

Murine peritoneal macrophages were cultured and placed on stainless steel, CoCrMo, and Ti6Al4V discs into a 96-well plate. Cells were activated with interferon gamma and lipopolysaccharide. Macrophages on stainless steel discs produced significantly more nitric oxide (NO) compared to their control counterparts after eight to ten days and remained elevated for the duration of the experiment.

RESULTS

On stainless steel, both nonactivated and activated cell groups were shown to have a significant increase in metal ion release for Cr, Fe, and Ni (p < 0.001, p = 0.002, and p = 0.020 respectively) compared with medium only and showed macrophage-sized corrosive pits on the stainless steel surface. On titanium alloy discs there was a significant increase in aluminum (p < 0.001) among all groups compared with medium only.

CONCLUSION

These results indicated that macrophages were able to attach to and affect the oxide surface of stainless steel and titanium alloy discs. Cite this article: Bone Joint J 2020;102-B(7 Supple B):116-121.

Metal-on-metal total hip arthroplasty adverse local tissue reaction with intermittent unilateral vascular claudication

Osteolysis and adverse local soft-tissue reactions are well-documented complications of metal-on-metal prosthetic implants. This case report describes a 68-year-old man who presented to the clinic 10 years after staged bilateral metal-on-metal total hip arthroplasty revisions with the primary complaint of groin pain, intermittent right leg pain, swelling, and muscle cramping while ambulating that resolved with rest. A complete workup was negative for deep venous thrombosis and infection. His symptoms were found to be secondary to an iliopsoas bursal mass externally compressing the femoral vasculature resulting in vascular claudication. He was treated with revision arthroplasty and drainage of the fluid within the iliopsoas bursal effusion with symptomatic resolution.

Trunnion Corrosion in Total Hip Arthroplasty-Basic Concepts

There has been increased interest in the role of corrosion in early implant failures and adverse local tissue reaction in total hip arthroplasty. We review the relationship between the different types of corrosion in orthopaedic surgery including uniform, pitting, crevice, and fretting or mechanically assisted crevice corrosion (MACC). Passive layer dynamics serves a critical role in each of these processes. The femoral head-neck trunnion creates an optimal environment for corrosion to occur because of the limited fluid diffusion, acidic environment, and increased bending moment.

Uniformly low serum cobalt levels after modular dual-mobility total hip arthroplasties with ceramic heads: a prospective study in high-risk patients

AIMS

Modular dual-mobility constructs reduce the risk of dislocation after revision total hip arthroplasty (THA). However, questions about metal ions from the cobalt-chromium (CoCr) liner persist, and are particularly germane to patients being revised for adverse local tissue reactions (ALTR) to metal. We determined the early- to mid-term serum Co and Cr levels after modular dual-mobility components were used in revision and complex primary THAs, and specifically included patients revised for ALTR.

PATIENTS AND METHODS

Serum Co and Cr levels were measured prospectively in 24 patients with a modular dual-mobility construct and a ceramic femoral head. Patients with CoCr heads or contralateral THAs with CoCr heads were excluded. The mean age was 63 years (35 to 83), with 13 patients (54%) being female. The mean follow-up was four years (2 to 7). Indications for modular dual-mobility were prosthetic joint infection treated with two-stage exchange and subsequent reimplantation (n = 8), ALTR revision (n = 7), complex primary THA (n = 7), recurrent instability (n = 1), and periprosthetic femoral fracture (n = 1). The mean preoperative Co and Cr in patients revised for an ALTR were 29.7 μg/l (2 to 146) and 21.5 μg/l (1 to 113), respectively.

RESULTS

Mean Co and Cr levels were 0.30 μg/l and 0.76 μg/l, respectively, at the most recent follow-up. No patient had a Co level ≥ 1 μg/l. Only one patient had a Cr level ≥ 1 μg/l. That patient's Cr level was 12 μg/l at 57 months after revision THA for ALTR (and decreased ten-fold from a preoperative Cr of 113 μg/l).

CONCLUSION

At a mean of four years, no patient with a modular dual-mobility construct and ceramic femoral head had elevated Co levels, including seven patients revised specifically for ALTR. While further studies are required, we support the selective use of a modular dual-mobility construct in revision and complex primary THAs for patients at high risk for instability. Cite this article: Bone Joint J 2019;101-B(6 Supple B):57-61.

Titanium neck-titanium stem taper corrosion in a modular neck stem

An 81-year-old woman presented with progressive groin pain after metal-on-polyethylene total hip arthroplasty with a modular neck stem and was found to have adverse local tissue reaction. As we report for the first time with this implant, we observed titanium neck-titanium stem taper corrosion intraoperatively. We also found head-neck taper corrosion. The patient underwent revision surgery to a modular fluted tapered stem with ceramic head and was asymptomatic at 3-year follow-up visit. In conclusion, consideration should be given to avoiding the routine use of this modular neck stem in total hip arthroplasty. Patients with this prosthesis should be closely monitored for adverse local tissue reaction.

Molecular pathology of adverse local tissue reaction caused by metal-on-metal implants defined by RNA-seq

Total hip arthroplasty (THA) alleviates hip pain and improves joint function. Current implant design permits long-term survivorship of THAs, but certain metal-on-metal (MoM) articulations can portend catastrophic failure due to adverse local tissue reactions (ALTR). Here, we identified biological and molecular differences between periacetabular synovial tissues of patients with MoM THA failure undergoing revision THA compared to patients undergoing primary THA for routine osteoarthritis (OA). Analysis of tissue biopsies by RNA-sequencing (RNA-seq) revealed that MoM patient samples exhibit significantly increased expression of immune response genes but decreased expression of genes related to extracellular matrix (ECM) remodeling. Thus, interplay between local tissue inflammation and ECM degradation may account for the pathology and compromised clinical outcomes in select patients with MoM implants. We conclude that adverse responses of host tissues to implant materials result in transcriptomic modifications in patients with MoM implants that permit consideration of strategies that could mitigate ECM damage.

A case of bilateral hip mechanically assisted crevice corrosion after staged total hip arthroplasty

Mechanically assisted crevice corrosion (MACC), also known as trunnionosis, and adverse local tissue reaction (ALTR) are entities that can lead to pain and necessitate revision in total hip arthroplasty (THA). We present a case of a 75-year-old female who received a bilateral staged primary THA with metal on cross-linked polyethylene implants and had subsequent bilateral revisions for MACC and ALTR. In both instances, she presented with anterior thigh pain, weakness, and difficulty ambulating, and she was revised to ceramic on cross-linked polyethylene implants. This case may suggest a biologic predisposition or systemic immunogenic reaction to metal debris in some patients with ALTR or represent an implant-specific complication. To our knowledge, this is the first case reported of a patient having bilateral MACC from staged THA performed by 2 different surgeons using the same brand implant.

Revision for adverse local tissue reaction following metal-on-polyethylene total hip arthroplasty is associated with a high risk of early major complications

Aims

Fretting and corrosion at the modular head/neck junction, known as trunnionosis, in total hip arthroplasty (THA) is a cause of adverse reaction to metal debris (ARMD). We describe the outcome of revision of metal-on-polyethylene (MoP) THA for ARMD due to trunnionosis with emphasis on the risk of major complications.

Patients and Methods

A total of 36 patients with a MoP THA who underwent revision for ARMD due to trunnionosis were identified. Three were excluded as their revision had been to another metal head. The remaining 33 were revised to a ceramic head with a titanium sleeve. We describe the presentation, revision findings, and risk of complications in these patients.

Results

The patients presented with pain, swelling, stiffness, or instability and an inflammatory mass was confirmed radiologically. Macroscopic material deposition on the trunnion was seen in all patients, associated with ARMD. Following revision, six (18.2%) dislocated, requiring further revision in four. Three (9.1%) developed a deep infection and six (18.2%) had significant persistent pain without an obvious cause. One developed a femoral artery thrombosis after excision of an iliofemoral pseudotumor, requiring a thrombectomy.

Conclusion

The risk of serious complications following revision MoP THA for ARMD associated with trunnionosis is high. In the presence of extensive tissue damage, a constrained liner or dual mobility construct is recommended in these patients. Cite this article: Bone Joint J 2018;100-B:720-4.

Pseudotumor in ceramic-on-metal total hip arthroplasty

The increasing demand for total hip arthroplasty (THA) in relatively young, high-demand patients has led to the use of hard-on-hard bearing surfaces. Adverse local tissue reaction/pseudotumor and elevated serum metal ion levels are commonly reported complications encountered in metal-on-metal THA, while audible articulation and rim fracture are reported in ceramic-on-ceramic THA. For this reason, ceramic-on-metal THA was implemented as an ideal hard-on-hard bearing combination. In this report, we describe a case of bilateral simultaneous ceramic-on-metal THA in a 69-year-old woman who presented 7 years postoperatively with unilateral hip pain associated with underlying pseudotumor and elevated serum cobalt and chromium ion levels. Pre-revision workup, intraoperative findings, and postoperative evaluation are included and suggest acetabular malposition as a potential source for complication.

Metal-on-metal total hip arthroplasty: risk factors for pseudotumours and clinical systematic evaluation

The potential advantages of contemporary MoM THA implants include less volumetric wear with subsequent reduction of polyethylene wear-induced osteolysis and greater component stability with use of large-diameter femoral heads. However, there have been concerns regarding significantly elevated revision rates in MoM THA due to MoM-related complications such as adverse local tissue reaction (pseudotumour) formation. The increased failure rate in MoM hip arthroplasty is associated with the generation of biologically active, nanometer sized metal particles from the MoM bearing surfaces and taper junctions, which result in the development of a localized, adverse periprosthetic soft tissue response. The focus of this article is to provide an update on (1) implant, surgical and patient factors associated with adverse local tissue reactions (pseudotumours) and (2) the clinical systematic evaluation and management of patients with MoM hip arthroplasty based on the currently available evidence. There should be a low threshold to conduct a systematic clinical evaluation of patients with MoM hip arthroplasty as early recognition and diagnosis will allow the initiation of prompt and appropriate treatment. As a symptomatic MoM total hip arthroplasty may have intrinsic and extrinsic causes, patients should be evaluated systematically, utilizing risk stratification algorithms. Although specialized laboratory tests such as metal ion levels and cross sectional imaging modalities such as MARS MRI can be used to facilitate clinical decision making, over-reliance on any single investigative tool in the clinical decision-making process should be avoided. Further research is required to obtain a better understanding of implant and patient risk factors associated with tribocorrosion in MoM total hip arthroplasty.

Histopathological characterization of corrosion product associated adverse local tissue reaction in hip implants: a study of 285 cases

Background

Adverse local tissue reaction (ALTR), characterized by a heterogeneous cellular inflammatory infiltrate and the presence of corrosion products in the periprosthetic soft tissues, has been recognized as a mechanism of failure in total hip replacement (THA). Different histological subtypes may have unique needs for longitudinal clinical follow-up and complication rates after revision arthroplasty. The purpose of this study was to describe the histological patterns observed in the periprosthetic tissue of failed THA in three different implant classes due to ALTR and their association with clinical features of implant failure.

Methods

Consecutive patients presenting with ALTR from three major hip implant classes (N = 285 cases) were identified from our prospective Osteolysis Tissue Database and Repository. Clinical characteristics including age, sex, BMI, length of implantation, and serum metal ion levels were recorded. Retrieved synovial tissue morphology was graded using light microscopy. Clinical characteristics and features of synovial tissue analysis were compared between the three implant classes. Histological patterns of ALTR identified from our observations and the literature were used to classify each case. The association between implant class and histological patterns was compared.

Results

Our histological analysis demonstrates that ALTR encompasses three main histological patterns: 1) macrophage predominant, 2) mixed lymphocytic and macrophagic with or without features of associated with hypersensitivity/allergy or response to particle toxicity (eosinophils/mast cells and/or lymphocytic germinal centers), and 3) predominant sarcoid-like granulomas. Implant classification was associated with histological pattern of failure, and the macrophagic predominant pattern was more common in implants with metal-on-metal bearing surfaces (MoM HRA and MoM LHTHA groups). Duration of implantation and composition of periprosthetic cellular infiltrates was significantly different amongst the three implant types examined suggesting that histopathological features of ALTR may explain the variability of clinical implant performance in these cases.

Conclusions

ALTR encompasses a diverse range of histological patterns, which are reflective of both the implant configuration independent of manufacturer and clinical features such as duration of implantation. The macrophagic predominant pattern and its mechanism of implant failure represent an important subgroup of ALTR which could become more prominent with increased length of implantation.

Revision for taper corrosion at the neck-body junction following total hip arthroplasty: pearls and pitfalls

The management of the patient with a recalled, modular neck-body total hip arthroplasty can be complex, as it involves a combination of clinical, technical, and medicolegal challenges. Management begins with a thorough history and physical exam, radiographic evaluation, infection workup, and serum metal ion levels. Three-dimensional imaging is obtained based on patient symptomatology and metal ion levels and is used to evaluate for the presence of an adverse local tissue response as well as the integrity of the existing soft tissue envelope. The decision to perform revision surgery is based on a combination of patient symptomatology, laboratory values, and imaging findings. Revision surgery involves the entire armamentarium of femoral revision techniques, and the acetabulum may need to be revised at the surgeon's discretion. The femoral implant can often be removed without disrupting the femoral bone envelope; however, the surgeon should have a low threshold to perform an extended trochanteric osteotomy.

Custom titanium sleeve for surgical treatment of mechanically assisted crevice corrosion in the well-fixed, noncontemporary stem in total hip arthroplasty

Adverse local tissue reaction associated with total hip replacement may occur when mechanically assisted crevice corrosion occurs at metal-metal modular junctions in which at least one of the components is fabricated from cobalt-chromium alloy. Complete removal of components may be associated with significant morbidity; when components are well fixed and in acceptable position, it may be appropriate to consider modular rather than complete revision. We have diagnosed mechanically assisted crevice corrosion in total hip arthroplasty patients with noncontemporary but well-fixed femoral components and found that modular conversion to a ceramic femoral head to remove a source of CoCr corrosion and fretting products was only possible by having a custom titanium sleeve manufactured. Surgical implantation with a revision style Biolox ceramic head (CeramTec, Plochingen, Germany) was then achieved.

Implant based differences in adverse local tissue reaction in failed total hip arthroplasties: a morphological and immunohistochemical study

BACKGROUND

Adverse local tissue reaction (ALTR) is characterized by periprosthetic soft tissue inflammation composed of a mixed inflammatory cell infiltrate, extensive soft tissue necrosis, and vascular changes. Multiple hip implant classes have been reported to result in ALTR, and clinical differences may represent variation in the soft tissue response at the cellular and tissue levels. The purpose of this study was to describe similarities and differences in periprosthetic tissue structure, organization, and cellular composition by conventional histology and immunohistochemistry in ALTR resulting from two common total hip arthroplasty (THA) implant classes.

METHODS

Consecutive patients presenting with ALTR from two major hip implant classes (N = 54 patients with Dual-Modular Neck implant; N = 14 patients with Metal-on-Metal implant) were identified from our prospective Osteolysis Tissue Database and Repository. Clinical characteristics including age, sex, BMI, length of implantation, and serum metal ion levels were recorded. Retrieved synovial tissue morphology was graded using light microscopy and cellular composition was assessed using immunohistochemistry.

RESULTS

Length of implantation was shorter in the DMN group versus MoM THA group (21.3 [8.4] months versus 43.6 [13.8] months respectively; p < 0.005) suggesting differences in implant performance. Morphologic examination revealed a common spectrum of neo-synovial proliferation and necrosis in both groups. Macrophages were more commonly present in diffuse sheets (Grade 3) in the MoM relative to DMN group (p = 0.016). Perivascular lymphocytes with germinal centers (Grade 4) were more common in the DMN group, which trended towards significance (p = 0.066). Qualitative differences in corrosion product morphology were seen between the two groups. Immunohistochemistry showed features of a CD4 and GATA-3 rich lymphocyte reaction in both implants, with increased ratios of perivascular T-cell relative to B-cell markers in the DMN relative to the MoM group (p = 0.032).

CONCLUSION

Our results demonstrate that both implant classes display common features of neo-synovial proliferation and necrosis with a CD4 and GATA-3 rich inflammatory infiltrate. Qualitative differences in corrosion product appearance, macrophage morphology, and lymphocyte distributions were seen between the two implant types. Our data suggests that ALTR represents a histological spectrum with implant-based features.

The local effects of metal corrosion in total hip arthroplasty

Corrosion has long been recognized to occur in total hip arthroplasty, but the local effects of this process have only recently become better understood. This article provides an overview of corrosion at modular junctions, and discusses the various etiologic factors for corrosion and the biologic response to metal debris released from this junction. Algorithms are provided for diagnosis and treatment, in accordance with the best available data.