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Kurtz MA, Hallab NJ, Rainey JP, Pelt CE, Mihalko WM, Piuzzi NS, Mont MA, Spece H, Kurtz SM. Metal Release in Total Knee Arthroplasty: A Review of Mechanisms, Adverse Local Tissue Reactions, and Biological Effects. J Arthroplasty 2025:S0883-5403(25)00237-2. [PMID: 40090503 DOI: 10.1016/j.arth.2025.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Revised: 03/06/2025] [Accepted: 03/07/2025] [Indexed: 03/18/2025] Open
Abstract
Compared to the hip, where investigators associate metal release with adverse local tissue reactions (ALTRs), metal-related complications in total knee arthroplasty (TKA) remain controversial and underexplored. Primary TKA systems use monobloc components, limiting corrosion and subsequent concerns. However, like the joints they replace, metal components degrade in vivo. In this narrative review, we aimed to summarize clinically relevant knowledge on metal release within the context of TKA for practicing orthopaedic surgeons. We asked: do ALTRs associated with metal release occur in the knee, and if so, to what extent? To answer this research question, we identified in vivo degradation mechanisms, including wear, mechanically assisted crevice corrosion, and electrocautery damage. Next, we synthesized case reports and retrospective clinical studies documenting ALTRs in primary and revision TKAs. Then, we reviewed the biological response to cobalt chrome debris, focusing on genotoxicity, immune responses, and hypersensitivity. While clinical evidence suggests that patients rarely experience severe biological reactions like pseudotumors, ALTRs associated with metal release can and do occur following TKA. To overcome knowledge gaps related to the prevalence of ALTR in TKA, prospective clinical trials are needed.
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Affiliation(s)
- Michael A Kurtz
- Drexel University Implant Research Core, Philadelphia, Pennsylvania
| | - Nadim J Hallab
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Joshua P Rainey
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Cristopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - William M Mihalko
- University of Tennessee Health Science Center, Campbell Clinic Orthopaedics, Memphis, Tennessee
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael A Mont
- The Rubin Institute, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Hannah Spece
- Drexel University Implant Research Core, Philadelphia, Pennsylvania
| | - Steven M Kurtz
- Drexel University Implant Research Core, Philadelphia, Pennsylvania
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2
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Sullivan MH, Gagnet PJ, Labott JR, Salomao DR, Houdek MT. Secondary Infection of Adverse Local Tissue Reaction Leading to Amputation in a Patient With a Modular Knee Endoprosthesis. J Am Acad Orthop Surg Glob Res Rev 2025; 9:01979360-202503000-00012. [PMID: 40096552 PMCID: PMC11913413 DOI: 10.5435/jaaosglobal-d-24-00293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Revised: 01/17/2025] [Accepted: 01/29/2025] [Indexed: 03/19/2025]
Abstract
Three years after endoprosthetic reconstruction of the proximal tibia, a patient presented with a skin ulceration near the surgical site. The knee was not clinically infected, but the patient had elevated serum cobalt levels. Dermatological evaluation diagnosed a friction ulcer. The ulcer failed to heal, and the patient underwent débridement and local flap advancement. Cultures grew Staphylococcus epidermidis, and they were treated with antibiotics. The ulceration recurred and repeated limb salvage was discussed, although eventually, the patient elected to undergo amputation. Pathology from the resected ulcer showed fibrinoid necrosis with aseptic lymphocytic vasculitis-associated lesion.
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Affiliation(s)
- Mikaela H. Sullivan
- From the Department of Orthopedic Surgery (Dr. Sullivan, Dr. Gagnet, Dr. Labott, Dr. Houdek); and the Department of Laboratory Medicine and Pathology (Dr. Salomao), Mayo Clinic, Rochester, MN
| | - Paul J. Gagnet
- From the Department of Orthopedic Surgery (Dr. Sullivan, Dr. Gagnet, Dr. Labott, Dr. Houdek); and the Department of Laboratory Medicine and Pathology (Dr. Salomao), Mayo Clinic, Rochester, MN
| | - Joshua R. Labott
- From the Department of Orthopedic Surgery (Dr. Sullivan, Dr. Gagnet, Dr. Labott, Dr. Houdek); and the Department of Laboratory Medicine and Pathology (Dr. Salomao), Mayo Clinic, Rochester, MN
| | - Diva R. Salomao
- From the Department of Orthopedic Surgery (Dr. Sullivan, Dr. Gagnet, Dr. Labott, Dr. Houdek); and the Department of Laboratory Medicine and Pathology (Dr. Salomao), Mayo Clinic, Rochester, MN
| | - Matthew T. Houdek
- From the Department of Orthopedic Surgery (Dr. Sullivan, Dr. Gagnet, Dr. Labott, Dr. Houdek); and the Department of Laboratory Medicine and Pathology (Dr. Salomao), Mayo Clinic, Rochester, MN
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Thever Y, Goh L, Yau Li SF, Siu Ling DH, Rong Chia SY, Ing How M. Adverse Local Tissue Reaction and Osteolysis After Ceramic-on-Ceramic Total Hip Arthroplasty. Arthroplast Today 2024; 30:101584. [PMID: 39717838 PMCID: PMC11665469 DOI: 10.1016/j.artd.2024.101584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Revised: 11/01/2024] [Accepted: 11/05/2024] [Indexed: 12/25/2024] Open
Abstract
Adverse local tissue reaction (ALTR) and osteolysis formation are more frequently described complications after total hip arthroplasty (THA) with metal-on-metal bearings. In this report, we present a unique case of ALTR and osteolysis formation with ceramic-on-ceramic bearing THA, which has been less commonly described in the existing literature. This rare case occurred in a 54-year-old patient who had a primary THA done 17 years prior to representing to our institution. As part of the workup for our patient to find out the underlying cause of his complications, we have carried out extensive investigations that have not been previously reported. We conclude that ceramic bearings in THA may not be entirely inert and may cause complications such as osteolysis and ALTR.
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Affiliation(s)
- Yogen Thever
- Department of Orthopaedic Surgery, Changi General Hospital, Singapore
| | - Lynne Goh
- Department of Anatomical Pathology, Changi General Hospital, Singapore
| | - Sam Fong Yau Li
- Department of Chemistry, National University of Singapore, Singapore
| | | | - Sean Yi Rong Chia
- Department of Chemistry, National University of Singapore, Singapore
| | - Moo Ing How
- Department of Orthopaedic Surgery, Changi General Hospital, Singapore
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Vijayakumar P, Mou Y, Li X, Anil J, Revi N, Cheng KY, Mathew MT, Bijukumar D. CoCrMo nanoparticle induces neurotoxicity mediated via mitochondrial dysfunction: a study model for implant derived nanoparticle effects. Nanotoxicology 2024; 18:707-723. [PMID: 39673117 PMCID: PMC11789272 DOI: 10.1080/17435390.2024.2438118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 11/14/2024] [Accepted: 11/25/2024] [Indexed: 12/16/2024]
Abstract
Toxicity associated with elevated levels of cobalt-chromium-molybdenum (CoCrMo) nanoparticles in total hip replacement (THR) patients has been a rising concern. Recent investigations demonstrated that these particles can induce polyneuropathy in THR patients. The current study aims to address a detailed molecular investigation of CoCrMo nanoparticle-mediated mitochondrial dynamics using induced pluripotent stem cell-derived neurons (iPSC neurons). Telencephalic neurons from iPSCs were used in this study. A statistically significant dose-dependent reduction in membrane potential and mitochondrial superoxide generation was observed after CoCrMo nanoparticle treatment. The gene expression analysis confirmed that the oxidative-specific genes were significantly upregulated in particle-treated cells compared to untreated cells. When iPSCs were exposed to CoCrMo nanoparticles, there was a significant reduction in the area, perimeter, and length of mitochondria. Live cell imaging (mitochondrial tracking) revealed a significant reduction in mitochondrial movements in the presence of CoCrMo nanoparticles. Further protein expression confirmed increased mitochondrial fission in CoCrMo particle-treated cells by significantly upregulating Drp-1 protein and downregulating Mfn-2. In conclusion, the results show that CoCrMo nanoparticles can significantly alter neuronal mitochondrial dynamics. The disturbance in balance restricts mitochondrial movement, reduces energy production, increases oxidative stress, and can cause subsequent neurodegeneration.
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Affiliation(s)
- Priyadarshini Vijayakumar
- Department of Biomedical Sciences, University of Illinois College of Medicine Rockford, Rockford, IL, USA
| | - Yongchao Mou
- Department of Biomedical Sciences, University of Illinois College of Medicine Rockford, Rockford, IL, USA
| | - Xuejun Li
- Department of Biomedical Sciences, University of Illinois College of Medicine Rockford, Rockford, IL, USA
| | - Jahnavi Anil
- Department of Biomedical Sciences, University of Illinois College of Medicine Rockford, Rockford, IL, USA
| | - Neeraja Revi
- Department of Biomedical Sciences, University of Illinois College of Medicine Rockford, Rockford, IL, USA
| | - Kai-Yuan Cheng
- Department of Biomedical Sciences, University of Illinois College of Medicine Rockford, Rockford, IL, USA
| | - Mathew T Mathew
- Department of Biomedical Sciences, University of Illinois College of Medicine Rockford, Rockford, IL, USA
| | - Divya Bijukumar
- Department of Biomedical Sciences, University of Illinois College of Medicine Rockford, Rockford, IL, USA
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Lyu Z, Meng X, Hu F, Wu Y, Ding Y, Long T, Qu X, Wang Y. Nanoscale ZnO doping in prosthetic polymers mitigate wear particle-induced inflammation and osteolysis through inhibiting macrophage secretory autophagy. Mater Today Bio 2024; 28:101225. [PMID: 39309162 PMCID: PMC11415586 DOI: 10.1016/j.mtbio.2024.101225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/27/2024] [Accepted: 09/01/2024] [Indexed: 09/25/2024] Open
Abstract
Wear particles produced by joint replacements induce inflammatory responses that lead to periprosthetic osteolysis and aseptic loosening. However, the precise mechanisms driving wear particle-induced osteolysis are not fully understood. Recent evidence suggests that autophagy, a cellular degradation process, plays a significant role in this pathology. This study aimed to clarify the role of autophagy in mediating inflammation and osteolysis triggered by wear particles and to evaluate the therapeutic potential of zinc oxide nanoparticles (ZnO NPs). We incorporated ZnO into the prosthetic material itself, ensuring that the wear particles inherently carried ZnO, providing a targeted and sustained intervention. Our findings reveal that polymer wear particles induce excessive autophagic activity, which is closely associated with increased inflammation and osteolysis. We identified secretory autophagy as a key mechanism for IL-1β secretion, exacerbating osteolysis. Both in vitro and in vivo experiments demonstrated that ZnO-doped particles significantly inhibit autophagic overactivation, thereby reducing inflammation and osteolysis. In summary, this study establishes secretory autophagy as a critical mechanism in wear particle-induced osteolysis and highlights the potential of ZnO-doped prosthetic polymers for targeted, sustained mitigation of periprosthetic osteolysis.
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Affiliation(s)
- Zhuocheng Lyu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiangchao Meng
- Department of Orthopedics, Minhang Hospital, Fudan University, Shanghai, China
| | - Fei Hu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yuezhou Wu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yurun Ding
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Teng Long
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - You Wang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Antoniac I, Valeanu N, Niculescu M, Antoniac A, Robu A, Popescu L, Manescu (Paltanea) V, Anusca D, Enachescu CI. Outcomes of Birmingham Hip Resurfacing Based on Clinical Aspects and Retrieval Analysis of Failed Prosthesis. MATERIALS (BASEL, SWITZERLAND) 2024; 17:3965. [PMID: 39203142 PMCID: PMC11355717 DOI: 10.3390/ma17163965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 08/06/2024] [Accepted: 08/07/2024] [Indexed: 09/03/2024]
Abstract
This research aims to identify the prevalence of failure for Birmingham Hip Prosthesis (BHR) in total hip arthroplasty and to analyze its reasons from biomaterials and biofunctional perspectives. We present our current analysis and tests on a series of different BHR-retrieved prostheses after premature failure. Relevant clinical data, such as X-ray investigations and intraoperative images for clinical case studies, were analyzed to better understand all factors involved in BHR prosthesis failure. A detailed analysis of the failures highlighted uneven cement distribution, overloading in certain areas, and void formation in the material. A closer investigation using microscopical techniques revealed the presence of a crack originating from the gap between the cement mantle and human bone. Additionally, scanning electron microscopy analyses were conducted as part of the investigation to examine bone cement morphology in detail and better understand the interactions at the interfaces between implant, cement, and bone. In conclusion, this research emphasizes the importance of surgical technique planning and the cementation procedure in the success rate of BHR prostheses. It also underscores the need to carefully evaluate patient characteristics and bone quality to minimize the risk of BHR prosthesis failure. The cementation procedure seems to be essential for the long-term functionality of the BHR prosthesis.
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Affiliation(s)
- Iulian Antoniac
- Faculty of Material Science and Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania; (I.A.); (N.V.); (A.R.); (L.P.); (V.M.)
- Academy of Romania Scientists, 54 Splaiul Independentei, RO-050094 Bucharest, Romania
| | - Niculae Valeanu
- Faculty of Material Science and Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania; (I.A.); (N.V.); (A.R.); (L.P.); (V.M.)
| | - Marius Niculescu
- Faculty of Medicine, Titu Maiorescu University, 67A Gheorghe Petrascu, RO-031593 Bucharest, Romania;
- Department of Orthopedics and Trauma I, Colentina Clinical Hospital, 19-21 Soseaua Stefan cel Mare, RO-020125 Bucharest, Romania
| | - Aurora Antoniac
- Faculty of Material Science and Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania; (I.A.); (N.V.); (A.R.); (L.P.); (V.M.)
| | - Alina Robu
- Faculty of Material Science and Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania; (I.A.); (N.V.); (A.R.); (L.P.); (V.M.)
| | - Larisa Popescu
- Faculty of Material Science and Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania; (I.A.); (N.V.); (A.R.); (L.P.); (V.M.)
| | - Veronica Manescu (Paltanea)
- Faculty of Material Science and Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania; (I.A.); (N.V.); (A.R.); (L.P.); (V.M.)
- Faculty of Electrical Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania
| | - Dan Anusca
- Department of Orthopedics, University of Medicine and Pharmacy of Craiova, 2-4 Petru Rares, RO-200349 Craiova, Romania;
| | - Catalin Ionel Enachescu
- Department of Dermatology, Elias Emergency University Hospital, 17 Bulevardul Marasti, RO-011461 Bucharest, Romania;
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Chen A, Kurmis AP. Understanding immune-mediated cobalt/chromium allergy to orthopaedic implants: a meta-synthetic review. ARTHROPLASTY 2024; 6:1. [PMID: 38303027 PMCID: PMC10835847 DOI: 10.1186/s42836-023-00227-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/12/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND The frequency of primary joint replacement surgery continues to increase worldwide. While largely considered biologically inert entities, an increasing body of evidence continues to validate a not insignificant incidence of allergic reactions to such implants. Little previous work has explored genuinely immune-mediated reactivity in this context. In the absence of a contemporary published summary on the topic, this paper explored the current state of understanding of cobalt/chromium allergy and proposes a patient management algorithm whereby such immune reactions are clinically suggested. METHODS A structured, systematic literature review was performed by following PRISMA search principles to provide an updated review of this area. RESULTS Thirty-six topic-related articles were identified, the majority reflecting lower tiers of scientific evidence with a lack of homogeneous quantitative data to facilitate valid cohort comparisons. Largely, the available literature represented small case series' or expert opinions. CONCLUSIONS Despite increasing clinical awareness and acknowledgement of true allergy to joint replacement components, this review highlighted that the evidence base underpinning the diagnosis and management of such patients is limited. Both patient-reported metal allergy or skin patch testing are grossly unreliable methods and show almost no correlation with true immune reactivity. Recent studies suggested a potential role for patient-specific in vitro cellular activation testing and/or targeted genetic testing when cobalt/chromium allergy is clinically suspected. However, while likely representing the contemporary "best available" approaches both can be costly undertakings, are not yet universally available, and still require broader validation in non-research settings before wider uptake can be championed.
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Affiliation(s)
- Arnold Chen
- School of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Andrew P Kurmis
- Discipline of Medical Specialties, University of Adelaide, Adelaide, SA, 5000, Australia.
- Department of Orthopaedic Surgery, Lyell McEwin Hospital, Elizabeth Vale, SA, 5112, Australia.
- College of Medicine & Public Health, Flinders University, Bedford Park, SA, 5042, Australia.
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Caicedo MS, Flores V, Siapno R, Crosby M, Samelko LA, Jacobs JJ, Hallab NJ. Establishing clinically meaningful ranges of metal hypersensitivity in orthopaedic patients using COVID-19 vaccine-induced adaptive immune responses from fully vaccinated adults. J Orthop 2024; 48:89-95. [PMID: 38089694 PMCID: PMC10711032 DOI: 10.1016/j.jor.2023.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 02/03/2025] Open
Abstract
Background This study aimed to assess metal sensitization ranges among orthopaedic patients by comparing adaptive immune responses in all-comer pre- and post-operative orthopaedic adults who were COVID-19 unvaccinated or vaccinated vs patients with a painful aseptic implant by lymphocyte transformation test (LTT) to SARS-CoV-2-Spike-Protein (SP) and implant metal(s), respectively. Methods Data were retrospectively reviewed from three independent groups: unvaccinated COVID-19 adults (n = 23); fully COVID-19 vaccinated adults (n = 35); unvaccinated, painful aseptic implant patients with history of metal allergy (n = 98). Standard in vitro LTT for SP and implant metal(s) (nickel, cobalt) were performed and rated as negative (stimulation index [SI]<2), mild (SI ≥ 2), positive (SI ≥ 4-15), and high sensitization (SI > 15) adaptive immune responses to tested antigen. Results Overall, 17/23 (74%) of unvaccinated adults showed negative to mild LTT ranges, and 35/35 (100%) of vaccinated showed mild to positive LTT ranges to SP. Vaccinated individuals showed significantly higher median SI (16.1) to SP than unvaccinated (median SI, 1.7; P < 0.0001). Most vaccinated adults (94%) showed a lymphocyte SI > 4 to SP, establishing LTT SI ≥ 4 with >90% sensitivity for diagnosing effective COVID-19 adaptive immune responses. Significantly fewer painful orthopaedic patients (41%) showed comparable elevated levels of lymphocyte metal sensitivity at SI ≥ 4 compared to vaccinated group (P < 0.0001). Conclusions Vaccinated adults showed significantly higher lymphocyte SI to SP than unvaccinated indicating that SI ranges ≥4 should be set as unequivocally diagnostic of LTT-positive adaptive immune responses to tested antigen. This analysis supports using higher LTT SI ranges (SI ≥ 4) in diagnosing clinical orthopaedic-related Type IV metal-hypersensitivity responses among orthopaedic patients.
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Affiliation(s)
- Marco S. Caicedo
- Orthopedic Analysis, LLC, Chicago, IL, 60612, USA
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | | | | | - Michael Crosby
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Lauryn A. Samelko
- Orthopedic Analysis, LLC, Chicago, IL, 60612, USA
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Joshua J. Jacobs
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Nadim J. Hallab
- Orthopedic Analysis, LLC, Chicago, IL, 60612, USA
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
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Cheng KY, Gupta P, Kanniyappan H, Zahurullah H, Sun Y, Alhamad M, Mathew MT. Survivability of Titanium Implant Materials: In Vitro Simulated Inflammatory and Infectious Environment. Ann Biomed Eng 2023; 51:2749-2761. [PMID: 37530907 PMCID: PMC10834857 DOI: 10.1007/s10439-023-03330-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 07/22/2023] [Indexed: 08/03/2023]
Abstract
Titanium-based implants utilized in total joint arthroplasties could restore primary musculoskeletal function to patients suffering from osteoarthritis and other conditions. Implants are susceptible to failure stemming from aseptic loosening and infection at the joint site, eventually requiring revision surgery. We hypothesized that there might be a feedback loop by which metal degradation particles and ions released from the implant decrease cell viability and increase immune response, thereby creating biochemical conditions that increase the corrosion rate and release more metal ions. This study focused on the synergistic process through cell viability assays and electrochemical tests. From the results, inflammatory conditions from ion release resulting in cell death would further increase the corrosion rate at the metal implant site. The synergistic interaction in the implant surroundings in which infectious conditions produce Ti ions that contribute to more infection, creating a potential cycle of accelerating corrosion.
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Affiliation(s)
- Kai Yuan Cheng
- Regenerative Medicine and Disability Research Lab, University of Illinois College of Medicine, Rockford, IL, USA
| | - Puranjay Gupta
- Regenerative Medicine and Disability Research Lab, University of Illinois College of Medicine, Rockford, IL, USA
| | - Hemalatha Kanniyappan
- Regenerative Medicine and Disability Research Lab, University of Illinois College of Medicine, Rockford, IL, USA
| | - Hamza Zahurullah
- Regenerative Medicine and Disability Research Lab, University of Illinois College of Medicine, Rockford, IL, USA
| | - Yani Sun
- Department of Biomedical Engineering, College of Engineering, University of Illinois , Chicago, IL, USA
| | - Mostafa Alhamad
- Department of Restorative Dentistry, College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA
- Department of Restorative Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Ad Dammām, Saudi Arabia
| | - Mathew T Mathew
- Regenerative Medicine and Disability Research Lab, University of Illinois College of Medicine, Rockford, IL, USA.
- Department of Restorative Dentistry, College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA.
- Department of Biomedical Engineering, College of Engineering, University of Illinois , Chicago, IL, USA.
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10
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Davis TP. Metal-on-Metal Hip Arthroplasty: A Comprehensive Review of the Current Literature. Cureus 2023; 15:e48238. [PMID: 37929272 PMCID: PMC10624517 DOI: 10.7759/cureus.48238] [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] [Accepted: 11/02/2023] [Indexed: 11/07/2023] Open
Abstract
Metal-on-metal (MoM) total hip arthroplasty has been widely used since the end of the 20th century, although rates have now decreased due to concerns regarding adverse reactions and failure rates. The MoM implant has been replaced with other materials, such as ceramic-on-ceramic (CoC) and metal-on-polyethylene (MoP). This literature review looks at the past and present use of MoM prostheses to assess whether the turn away from MoM use is justified. Online literature searches were performed on PubMed, Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), and Web of Science online databases using the search terms "MoM and (ARMD and ALVAL)" (ARMD: adverse reaction to metal debris; ALVAL: aseptic lymphocyte-dominant vasculitis-associated lesion). A total of 64 relevant titles were included in the review. Although risk factors for adverse reactions and the causes of ARMD are generally agreed upon, more work is required to further understand the specific thresholds of blood metal ion levels that can be used to consistently identify ARMD and excessive metal wear-debris in patients who have not had their MoM implants revised. Metal-on-metal devices are not an acceptable option for total hip arthroplasties (THAs) in their current formulation due to the high rate and risk of ARMD. Some MoM hip resurfacing operations are appropriate for very carefully selected patients who are fully aware of the risks posed by the implant. It is recommended that device-specific thresholds for metal ion levels be developed to identify patients at risk of ARMD locally and systemically while using auxiliary tools to assist diagnosis, such as metal artefact reduction sequences (MARS)-MRI and hip scoring tools. Further work should investigate device-specific blood metal ion levels, the systemic effects of raised metal ion concentrations secondary to MoM arthroprosthetic wear, and the potential risks of ARMD caused by wear from tapered stems (including the implications this has for patients with CoC and MoP prostheses).
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Affiliation(s)
- Timothy P Davis
- Department of Anatomy, University of Nottingham Medical School, Nottingham, GBR
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11
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Zheng C, Xu J, Wu L, Wu Y, Liu Y, Shen B. Comparisons of Different Bearing Surfaces in Cementless Total Hip Arthroplasty: A Systematic Review and Bayesian Network Analysis. J Arthroplasty 2023; 38:600-609. [PMID: 36265721 DOI: 10.1016/j.arth.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/06/2022] [Accepted: 10/11/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND We aimed to make comparisons of different bearing surfaces in patients after cementless total hip arthroplasty. METHODS The network meta-analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. The primary outcomes were implant survival and Harris hip score (HHS). Secondary outcomes included linear wear rates and serum level of metal ions. Subgroup analyses were performed by: (1) classifying head sizes as small and large; (2) femoral heads as ceramic and metal; and (3) liners as metal, ceramic, polyethylene, highly cross-linked polyethylene (HXP), or vitamin E-infused highly cross-linked polyethylene (HXPE). A total of 64 eligible RCTs with different bearings were assessed. Overall inconsistency and heterogeneity were acceptable. RESULTS In the 10 years follow-up, metal-on-polythene and ceramic-on-polythene bearings with small heads showed higher risk for revisions compared with metal-on-HXP and ceramic-on-HXP bearings with small heads. Similarly, only metal or ceramic-on-polythene bearings with small heads showed inferiority in HHS compared with other bearings. Conventional polyethylene liners showed higher linear wear rates compared with HXP, HXPE, and ceramic liners at 5 and 10 years after surgery, while metal-on-metal and ceramic-on-metal bearings showed higher serum level of cobalt and chromium. CONCLUSION Bearings containing HXP, HXPE, and ceramic liners showed comparable survivorship and hip function at follow-up of 5 and 10 years. Hard-on-hard bearings containing metal had higher serum level of metal ions than others. Bearings containing conventional polyethylene had worse performance in terms of implant survival, hip function, and wear rates. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Che Zheng
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jiawen Xu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Liming Wu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yuangang Wu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yuan Liu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bin Shen
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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12
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[Particle disease and its effects on periarticular tissue]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:196-205. [PMID: 36867226 DOI: 10.1007/s00132-023-04348-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 03/04/2023]
Abstract
Particle disease is the condition caused by wear debris on surrounding tissues and influences the well-being of arthroplasty patients. This condition is multifactorial due to the type of bearing couple, head size and implant position. Subsequent periprosthetic osteolysis and soft tissue reactions, can lead to revision THA surgery. The periprosthetic synovial membrane (synovial-like interface membrane, SLIM) is used in diagnostics when the cause of implant failure is uncertain. Detailed analysis of synovial fluid and bone marrow could improve the diagnostic procedure and strengthen the cases for revision surgery and the underlying biology. A large number of research approaches on this topic have evolved and continue to be utilized in the clinic.
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13
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Clinical Outcomes, Metal Ion Levels, Lymphocyte Profiles, and Implant Survival Following Five Different Bearings of Total Hip Arthroplasty: A Mean 10-year Follow-up Study. J Arthroplasty 2022; 37:2053-2062. [PMID: 35490981 DOI: 10.1016/j.arth.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/15/2022] [Accepted: 04/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Different bearings have been used in total hip arthroplasty (THA), but the long-term performance is still controversial. The purpose of this study was to investigate whether there are differences when comparing THAs with 5 different bearings at a long-term follow-up of more than 10 years. METHODS From January 2010 to May 2012, 101 THA patients (134 hips) were divided into metal-on-metal group (MoM, 31 hips), metal-on-polyethylene group (MoP, 23 hips), ceramic-on-metal group (CoM, 21 hips), ceramic-on-ceramic group (CoC, 33 hips), and ceramic-on-polyethylene group (CoP, 26 hips). The mean follow-up period was 10.3 years. The Harris hip score (HSS), Western Ontario and McMaster Universities Osteoarthritis Index scores (WOMAC), range of motion (ROM), blood cell count, and liver-kidney function were measured. Serum and urine metal ion levels were measured using high-resolution inductively coupled plasma-mass spectrometry (ICP-MS) and a blood lymphocytes analysis was counted by flow cytometry. RESULTS No difference was observed in the HSS, WOMAC, ROM, blood cell count, or liver-kidney function among any of the 5 groups. Metal ion levels were significantly elevated in metal-containing bearings. Flow cytometry showed that no differences were found. Revision was performed due to pseudotumor in 3 patients. The implant survival rate was 96.7% and 93.3% for the MoM and CoC groups, which was significantly lower compared with other groups. CONCLUSIONS Metal ion levels were elevated significantly in metal-containing bearings, especially in MoM THA patients. The implant survival rate was significantly lower in CoC and MoM THAs, which was mainly due to pseudotumor formation. LEVEL OF EVIDENCE Therapeutic Level II.
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Involvement of NF-κB/NLRP3 axis in the progression of aseptic loosening of total joint arthroplasties: a review of molecular mechanisms. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:757-767. [PMID: 35377011 DOI: 10.1007/s00210-022-02232-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
Abstract
Particulate wear debris can trigger pro-inflammatory bone resorption and result in aseptic loosening. This complication remains major postoperative discomforts and complications for patients who underwent total joint arthroplasty. Recent studies have indicated that wear debris-induced aseptic loosening is associated with the overproduction of pro-inflammatory cytokines. The activation of osteoclasts as a result of inflammatory responses is associated with osteolysis. Moreover, stimulation of inflammatory signaling pathways such as the NF-κB/NLRP3 axis results in the production of pro-inflammatory cytokines. In this review, we first summarized the potential inflammatory mechanisms of wear particle-induced peri-implant osteolysis. Then, the therapeutic approaches, e.g., biological inhibitors, herbal products, and stem cells or their derivatives, with the ability to suppress the inflammatory responses, mainly NF-κB/NLRP3 signaling pathways, were discussed. Based on the results, activation of macrophages following inflammatory stimuli, overproduction of pro-inflammatory cytokines, and subsequent differentiation of osteoclasts in the presence of wear particles lead to bone resorption. The activation of NF-κB/NLRP3 signaling pathways within the macrophages stimulates the production of pro-inflammatory cytokines, e.g., IL-1β, IL-6, and TNF-α. According to in vitro and in vivo studies, novel therapeutics significantly promoted osteogenesis, suppressed osteoclastogenesis, and diminished particle-mediated bone resorption. Conclusively, these findings offer that suppressing pro-inflammatory cytokines by regulating both NF-κB and NLRP3 inflammasome represents a novel approach to attenuate wear-particle-related osteolytic diseases.
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15
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Langton DJ, Bhalekar RM, Joyce TJ, Rushton SP, Wainwright BJ, Nargol ME, Shyam N, Lie BA, Pabbruwe MB, Stewart AJ, Waller S, Natu S, Ren R, Hornick R, Darlay R, Su EP, Nargol AVF. The influence of HLA genotype on the development of metal hypersensitivity following joint replacement. COMMUNICATIONS MEDICINE 2022; 2:73. [PMID: 35761834 PMCID: PMC9232575 DOI: 10.1038/s43856-022-00137-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 06/07/2022] [Indexed: 12/27/2022] Open
Abstract
Background Over five million joint replacements are performed across the world each year. Cobalt chrome (CoCr) components are used in most of these procedures. Some patients develop delayed-type hypersensitivity (DTH) responses to CoCr implants, resulting in tissue damage and revision surgery. DTH is unpredictable and genetic links have yet to be definitively established. Methods At a single site, we carried out an initial investigation to identify HLA alleles associated with development of DTH following metal-on-metal hip arthroplasty. We then recruited patients from other centres to train and validate an algorithm incorporating patient age, gender, HLA genotype, and blood metal concentrations to predict the development of DTH. Accuracy of the modelling was assessed using performance metrics including time-dependent receiver operator curves. Results Using next-generation sequencing, here we determine the HLA genotypes of 606 patients. 176 of these patients had experienced failure of their prostheses; the remaining 430 remain asymptomatic at a mean follow up of twelve years. We demonstrate that the development of DTH is associated with patient age, gender, the magnitude of metal exposure, and the presence of certain HLA class II alleles. We show that the predictive algorithm developed from this investigation performs to an accuracy suitable for clinical use, with weighted mean survival probability errors of 1.8% and 3.1% for pre-operative and post-operative models respectively. Conclusions The development of DTH following joint replacement appears to be determined by the interaction between implant wear and a patient's genotype. The algorithm described in this paper may improve implant selection and help direct patient surveillance following surgery. Further consideration should be given towards understanding patient-specific responses to different biomaterials.
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Affiliation(s)
- David J. Langton
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, England
| | - Rohan M. Bhalekar
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, England
| | | | | | | | - Matthew E. Nargol
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, England
| | - Nish Shyam
- ExplantLab, The Biosphere, Newcastle Helix, Newcastle-upon-Tyne, England
| | - Benedicte A. Lie
- Department of Medical Genetics, University of Oslo and Oslo University Hospital, Oslo, Norway
| | | | - Alan J. Stewart
- School of Medicine, University of St Andrews, St Andrews, Scotland
| | - Susan Waller
- University Hospital of North Tees, Stockton, England
| | - Shonali Natu
- University Hospital of North Tees, Stockton, England
| | - Renee Ren
- Hospital for Special Surgery, New York, USA
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16
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Bodiga VL, Vemuri PK, Kudle MR, Bodiga S. Ellagic Acid from Terminalia arjuna Fruits Protects Against Chromium and Cobalt Toxicity in Primary Human Lymphocytes. Biol Trace Elem Res 2022; 200:2698-2708. [PMID: 34432268 DOI: 10.1007/s12011-021-02900-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/21/2021] [Indexed: 12/28/2022]
Abstract
Increased accumulation of heavy metal ions such as Cr6+ and Co2+ due to release from prostheses and metallic implants has been reported. These metal ions have been shown to affect both resting and activated lymphocytes. Natural remedies towards mitigating the cytotoxic effects of metal ions are clearly warranted. Polyphenolic compounds which are part of hydrolysable tannins from natural plant sources are considered effective in cheating heavy metal ions in a biological system. We have isolated and characterized a polyphenolic compound (ellagic acid) from Terminalia arjuna fruits that has been tested for its ability to attenuate the metal ion toxicity in primary human lymphocytes in culture. Cr6+ and Co2+ (100 μM) decreased lymphocyte viability and proliferation and increased apoptosis of resting as well as CD3 and/or CD28-stimulated lymphocytes. Metal ions markedly diminished the cytokine (interleukin-2 and interferon-γ) secretion from activated lymphocytes. Pretreatment with ellagic acid at 25, 50, and 100 μM concentrations effectively improved viability and proliferative responses of both resting and activated lymphocytes, while attenuating the apoptotic index. Ellagic acid also tended to normalize the cytokine secretion from the activated lymphocytes even in the presence of metal ions, suggesting broad effects on the adaptive immune system.
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Affiliation(s)
- Vijaya Lakshmi Bodiga
- Department of Biochemistry and Molecular Biology, Institute of Genetics & Hospital for Genetic Diseases, Osmania University, Begumpet, Hyderabad, Telangana, India
| | - Praveen Kumar Vemuri
- Department of Biotechnology, Koneru Lakshmaiah University, Green Fields, Vaddeswaram, Guntur, Andhra Pradesh, India
| | - Madhukar Rao Kudle
- Department of Biochemistry, Kakatiya University, Warangal, Telangana, India
| | - Sreedhar Bodiga
- Laboratory of Biochemistry, Department of Basic Sciences, Forest College and Research Institute Hyderabad, Siddipet District Telangana, Mulugu, India.
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17
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Abe T, Otani T, Hayama T, Fujii H, Kawaguchi Y, Saito M. Revision Total Hip Arthroplasty Using the Modular Proximal Stem Modified for Asians: Medium-Term Clinical Results and Perioperative Complications. J Arthroplasty 2022; 37:770-776. [PMID: 34990756 DOI: 10.1016/j.arth.2021.12.037] [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: 09/10/2021] [Revised: 12/22/2021] [Accepted: 12/28/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aimed to examine the medium-term clinical and radiological outcomes of revision THA using the S-ROM-A stem, a modification of the S-ROM stem intended for Asians. METHODS Femoral reconstruction using the S-ROM-A stem was performed in 126 hips that underwent revision THA. All patients were followed for perioperative complications. In addition, clinical and radiographic outcomes at a mean of 8 (range 5-14) years postoperatively were evaluated in 96 hips of 86 patients (76%). RESULTS The most common perioperative complication was a femoral fracture, occurring in 16 hips (13%), including 11 intraoperative and 5 postoperative fractures. Dislocation occurred in five hips (4.0%), infection in three hips (2.4%), and trunnionosis in two hips (1.6%), including late complications. The total second stem revision was performed in two hips while stem only second revision preserving the bone ingrown sleeve was performed in four hips. With a second revision for aseptic loosening as the endpoint, the 13-year stem survival rate was 100%. Hip function as assessed by the Japanese Orthopedic Association score improved from a mean of 48 points preoperatively to 87 points 8 years postoperatively (P < .05). Radiological evaluation at the final follow-up showed that 95 hips (99%) achieved bone ingrowth fixation and one hip (1%) achieved fibrous stable status. CONCLUSION Revision THA using the S-ROM-A stem resulted in good medium-term outcomes. Although modifications of the stem length and shape may be effective in preventing fractures in Asians with relatively small body sizes, attention should be paid to the occurrence of trunnionosis, which may be associated with the decreased taper size.
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Affiliation(s)
- Toshiomi Abe
- Department of Orthopaedic Surgery, The Jikei University KASHIWA Hospital, Chiba, Japan
| | - Takuya Otani
- Department of Orthopaedic Surgery, The Jikei University DAISAN Hospital, Tokyo, Japan
| | - Tetsuo Hayama
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hideki Fujii
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yasuhiko Kawaguchi
- Department of Orthopaedic Surgery, The Jikei University DAISAN Hospital, Tokyo, Japan
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
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18
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Vogel D, Henke P, Haenel A, Mokros J, Liebelt M, Bader R. Experimental evaluation of the primary fixation stability of uncemented ceramic hip resurfacing implants. Proc Inst Mech Eng H 2022; 236:9544119211070892. [PMID: 35166142 DOI: 10.1177/09544119211070892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
Hip resurfacing arthroplasty is associated with increased frictional moments compared to standard heads owing to their large diameter. High frictional moments may harbor the risk of the implant loosening if the frictional moments exceed the fixation stability of the hip resurfacing arthroplasty. Therefore, the aim of this experimental study was to evaluate the fixation stability of ceramic hip resurfacing implants through a turn-off test. The test specimens, made of alumina toughened zirconia (ATZ) ceramics with an inner titanium-coated surface and square base bodies for better application to the test setup, were pushed on artificial bone materials until a predefined seating depth was achieved. Thereafter, the specimens were turned off from the artificial bone material by using a lever-arm and the turn-off moments were calculated. The density of the artificial bone material utilized (15 and 25 pcf), the press-fit (0.4 and 0.8 mm) and the size of the test specimens varied. The push-on forces ranged from 0.6 ± 0.1 kN to 5.6 ± 0.5 kN depending on the press-fit and artificial bone material. The turn-off moments relied on the respective press-fit, artificial bone material and size of the specimen. They belonged between the range of 8.5 ± 0.4 Nm and 105.4 ± 0.2 Nm. Most of the previously described frictional moments are lower compared to the turn-off moments determined in this study. However, in the worst-case scenario, the turn-off moments of the hip resurfacing implants may be reduced, especially when the adjacent bone stock has a low mineral density.
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Affiliation(s)
- Danny Vogel
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany
| | - Paul Henke
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany
| | | | - Jan Mokros
- Mathys Orthopaedie GmbH, Moersdorf, Germany
| | | | - Rainer Bader
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany
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19
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Bogdanova-Bennett A, Sagi A, Asopa V, Field RE, Sochart DH. Nickel hypersensitivity and skin patch testing in total hip replacement surgery: a systematic review. EFORT Open Rev 2021; 6:825-838. [PMID: 34760283 PMCID: PMC8559563 DOI: 10.1302/2058-5241.6.210051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Approximately 60,000 cemented femoral stems are implanted in the UK each year with the majority being manufactured from stainless steel containing 10–15% nickel. Nickel hypersensitivity has been reported in up to 13% of the general population and there is a concern that nickel hypersensitivity might adversely affect the outcome of total hip replacement (THR). We reviewed the current literature on the potential link between nickel hypersensitivity and THR complications, and the usefulness of patch testing. We conducted a literature search in PubMed, MEDLINE and EMBASE databases. The level of evidence and the quality of the selected studies were assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the Methodological Index for Non-Randomised Studies tool, respectively. Twenty-six studies met the inclusion criteria, reporting on 1852 patients who underwent primary or revision THR. All studies detailed skin patch testing and recorded prevalence of nickel hypersensitivity from 1.5% to 33.3%. Five studies reported a rise in Nickel hypersensitivity following THR, while four reported a decreased prevalence post-operatively. Eight studies concluded that metal hypersensitivity could have developed following THR, while seven studies did not support a link between metal hypersensitivity and THR complications. Four of the studies recommended routine patch testing pre-operatively, but three others concluded that routine patch testing was not indicated. We have not identified a link between nickel hypersensitivity and THR complications, and the role of patch testing remains unclear. Further large-scale studies would be required to investigate this relationship and to clarify the role of patch testing in facilitating implant selection. Cite this article: EFORT Open Rev 2021;6:825-838. DOI: 10.1302/2058-5241.6.210051
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Affiliation(s)
| | - Amit Sagi
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
| | - Vipin Asopa
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
| | - Richard E Field
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
| | - David H Sochart
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
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20
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Manfreda F, Bufi E, Florio EF, Ceccarini P, Rinonapoli G, Caraffa A, Antinolfi P. Osteolysis in total hip arthroplasty in relation to metal ion release: Comparison between monolithic prostheses and different modularities. World J Orthop 2021; 12:768-780. [PMID: 34754833 PMCID: PMC8554354 DOI: 10.5312/wjo.v12.i10.768] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/30/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Among the various complications associated with total hip arthroplasty (THA) periprosthetic osteolysis and wear phenomena due to the release of metal particles, are two of the most common and have been reported to be correlated because of inflammatory responses directed towards released particles that generally activate macrophagic osteolytic effects. Therein, new masses known as pseudotumors can appear in soft tissues around a prosthetic implant. To date, there is paucity of reliable data from studies investigating for any association between the above mentioned adverse events.
AIM To investigate for the existence of any association between serum and urine concentrations of metal-ions released in THA and periprosthetic osteolysis for modular neck and monolithic implants.
METHODS Overall, 76 patients were divided into three groups according to the type of hip prosthesis implants: Monoblock, modular with metal head and modular with ceramic head. With an average f-up of 4 years, we conducted a radiological evaluation in order to detect any area of osteolysis around the prosthesis of both the femur and the acetabulum. Moreover, serum and urinary tests were performed to assess the values of Chromium and Cobalt released. Statistical analysis was performed to determine any association between the ion release and osteolysis.
RESULTS For the 3 study groups, the monolithic, modular ceramic-headed and modular metal-headed implants had different incidences of osteolysis events, which were higher for the modular implants. Furthermore, the most serious of these (grade 3) were detected almost exclusively for the modular implants with metal heads. A mapping of the affected areas was performed revealing that the highest incidences of osteolysis were evidenced in the pertrochanteric region at the femur level, and in the supero-external region at the acetabular level. Regarding the evaluation of the release of metals-ions from wear processes, serum and urinary chromium and cobalt values were found to be higher in cases of modularity, and even more so for those with metal head. Statistical linear correlation test results suggested positive correlations between increasing metal concentrations and incidences areas of osteolysis. However, no cases of pseudo-tumor were detected.
CONCLUSION Future studies are needed to identify risk factors that increase peri-prosthetic metal ion levels and whether these factors might be implicated in the triggering of local events, including osteolysis and aseptic loosening.
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Affiliation(s)
- Francesco Manfreda
- Division of Orthopedics and Trauma Surgery, Santa Maria della Misericordia Hospital, Perugia 06100, Italy
- Department of Orthopedics and Traumatology, University of Perugia, Perugia 06100, Italy
| | - Egzon Bufi
- Department of Orthopedics and Traumatology, University of Perugia, Perugia 06100, Italy
| | - Enrico Francesco Florio
- Department of Orthopaedic and Traumatology, Infermi Hospital, AUSL Romagna, Rimini 47921, Italy
| | - Paolo Ceccarini
- Department of Orthopedics and Traumatology, University of Perugia, Perugia 06100, Italy
| | | | - Auro Caraffa
- Department of Orthopedics and Traumatology, University of Perugia, Perugia 06100, Italy
| | - Pierluigi Antinolfi
- Department of Orthopedics and Traumatology, University of Perugia, Perugia 06100, Italy
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21
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Hodges NA, Sussman EM, Stegemann JP. Aseptic and septic prosthetic joint loosening: Impact of biomaterial wear on immune cell function, inflammation, and infection. Biomaterials 2021; 278:121127. [PMID: 34564034 DOI: 10.1016/j.biomaterials.2021.121127] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 12/17/2022]
Abstract
The success of total joint replacements has led to consistent growth in the use of arthroplasty in progressively younger patients. However, more than 10 percent of patients require revision surgeries due to implant failure caused by osteolytic loosening. These failures are classified as either aseptic or septic and are associated with the presence of particulate wear debris generated by mechanical action between implant components. Aseptic loosening results from chronic inflammation caused by activation of resident immune cells in contact with implant wear debris. In contrast, septic loosening is defined by the presence of chronic infection at the implant site. However, recent findings suggest that subclinical biofilms may be overlooked when evaluating the cause of implant failure, leading to a misdiagnosis of aseptic loosening. Many of the inflammatory pathways contributing to periprosthetic joint infections are also involved in bone remodeling and resorption. In particular, wear debris is increasingly implicated in the inhibition of the innate and adaptive immune response to resolve an infection or prevent hematogenous spread. This review examines the interconnectivity of wear particle- and infection-associated mechanisms of implant loosening, as well as biomaterials-based strategies to combat infection-related osteolysis.
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Affiliation(s)
- Nicholas A Hodges
- University of Michigan, Department of Biomedical Engineering, Ann Arbor, MI, 48109, USA; Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, FDA, Silver Spring, MD, 20993, USA.
| | - Eric M Sussman
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, FDA, Silver Spring, MD, 20993, USA.
| | - Jan P Stegemann
- University of Michigan, Department of Biomedical Engineering, Ann Arbor, MI, 48109, USA.
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22
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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: 6.0] [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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Sumiyoshi N, Oinuma K, Miura Y. Small-head metal on metal total hip arthroplasty is associated with a high rate of complication and reoperation at mid-term follow-up. SAGE Open Med 2021; 9:20503121211014707. [PMID: 34035911 PMCID: PMC8132082 DOI: 10.1177/20503121211014707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/13/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Adverse reactions to metal debris are significant complications after metal-on-metal total hip arthroplasty. Recently, late appearances of adverse reactions to metal debris and subsequent need for reoperations have been reported with small-diameter head metal-on-metal devices. We retrospectively investigated mid-term clinical outcomes of small-head metal-on-metal total hip arthroplasty. Methods: We reviewed 159 hips in 139 patients who had a small-head metal-on-metal total hip arthroplasty (M2a Taper; Biomet, Warsaw, IN) with a minimum 5-year follow-up and documented postoperative complications. Results: Focal osteolysis in either the femur or acetabulum was observed in 12 hips (7.5%, 44 months after surgery on average), with pseudotumor observed in 8 hips (5%, 120 months after surgery on average). Four hips (2.5%) had dislocations (84 months after surgery on average) and six hips (3.8%, 122 months after surgery on average) underwent reoperation. Conclusion: Small-head metal-on-metal total hip arthroplasty is associated with a high degree of complications at mid-term follow-up period. Considering this, we discourage the use of metal-on-metal total hip arthroplasty regardless of head size.
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Affiliation(s)
| | | | - Yoko Miura
- Funabashi Orhopaedic Hospital, Funabashi, Chiba, Japan
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Röhner E, Heinecke M, Matziolis G. Diagnostic algorithm in aseptic TKA failure - What is evidence-based? J Orthop 2021; 24:248-253. [PMID: 33854292 PMCID: PMC8039505 DOI: 10.1016/j.jor.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- E. Röhner
- Corresponding author. Orthopaedic Department, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany.
| | | | - G. Matziolis
- Orthopaedic Department of the Waldkliniken Eisenberg, University Hospital Jena, 07607, Eisenberg, Germany
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Malahias MA, Bauer TW, Gu A, Nocon AA, De Martino I, Sculco PK. Questioning the Clinical Relevance of Positive Post-implantation Allergy Testing for Metal Hypersensitivity in Total Knee Arthroplasty: A Didactic Case Report. HSS J 2020; 16:485-489. [PMID: 33380984 PMCID: PMC7749884 DOI: 10.1007/s11420-019-09710-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/02/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Michael-Alexander Malahias
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 USA
| | - Thomas W. Bauer
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021 USA
| | - Alex Gu
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 USA
| | - Allina A. Nocon
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 USA
| | - Ivan De Martino
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 USA
| | - Peter K. Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 USA
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Laumonier T, Ruffieux E, Paccaud J, Kindler V, Hannouche D. In vitro evaluation of human myoblast function after exposure to cobalt and chromium ions. J Orthop Res 2020; 38:1398-1406. [PMID: 31883135 DOI: 10.1002/jor.24579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 12/23/2019] [Indexed: 02/04/2023]
Abstract
The replacement of a native hip joint by a metal-on-metal prosthesis may induce deleterious inflammatory side effects that are associated with the release of wear particles and metal ions. These events are referred to the adverse reaction to metal debris (ARMD) and the adverse local tissue reaction (ALTR). While wear particles seem involved in ARMD, the role of metal ions in ALTR and their impact on myoblasts, located in the prosthesis vicinity, has not been fully identified. To clarify this issue we investigated, using an in vitro culture system, the effect of cobalt and/or chromium ions (Co2+ and/or Cr3+ ) on human myoblast proliferation, cellular differentiation, and inflammatory marker expression. Freshly isolated human myoblasts were cultured in media supplemented with graded concentrations of Co2+ and/or Cr3+ . Co2+ induced a concentration-dependent decrease of both myoblast viability and myogenic differentiation while Cr3+ did not. Co2+ or Co2+ /Cr3+ also induced the upregulation of ICAM-1, whereas HLA-DR expression was unaffected. Moreover, allogenic monocytes induced the synergistic increase of Co2+ -induced ICAM-1 expression. We also found that Co2+ stabilized HIF-1α and increased TLR4, tumor necrosis factor-alpha (TNF-α), and interleukin 1β (IL-1β) expression in a dose and time-dependent manner in human myoblasts. This study showed that Co2+ , but not Cr3+ , was toxic toward myoblasts and induced, in the surviving cells, expression of inflammatory markers such as ICAM-1, TLR4, TNF-α, and IL-1β. This suggests that Co2+ , most efficiently in the presence of monocytes, may be a key inducer of ALTR, which may, if severe and long-lasting, eventually result in prosthesis loosening.
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Affiliation(s)
- Thomas Laumonier
- Department of Orthopedic Surgery, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Etienne Ruffieux
- Department of Orthopedic Surgery, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Joris Paccaud
- Department of Orthopedic Surgery, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Vincent Kindler
- Department of Orthopedic Surgery, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Didier Hannouche
- Department of Orthopedic Surgery, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
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Hobza M, Milde D, Slobodova Z, Gallo J. The number of lymphocytes increases in the periprosthetic tissues with increasing time of implant service in non-metal-on-metal total joint arthroplasties: A role of metallic byproducts? Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 165:416-427. [PMID: 32435063 DOI: 10.5507/bp.2020.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/27/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The objective of the study was to determine the association between periprosthetic concentrations of selected metals and changes induced in periprosthetic tissues (PT). METHODS PT from 24 patients with metal-on-polyethylene or ceramic-on-polyethylene total joint replacements (TJRs) were examined. Samples underwent histological examination including quantification of cellular populations. Determination of metals was performed according to the published methodology. Results were processed using correlation analysis and Principal Component Analysis (PCA), respectively. RESULTS Growing concentration of metals in the PT was found as a function of length of exposure (LoE). Differences in Ti, Co, Cr and V concentrations (per α = 0.05) depended on the type of alloy the implants were made from. On the contrary, the implant composition did not reflect in the different numbers of immune cells per 1 high power field, not even in distribution of the membrane type according to the Krenn classification. PCA revealed several clusters in dependence on the LoE, type of the membrane and presence of immune cells. High representation of lymphocytes in the PT was typical for clusters with the longest LoE while a higher representation of neutrophils was typical for a shorter time to reoperation. CONCLUSIONS Correlation between the LoE and concentrations of metals in its surroundings was demonstrated. However, the tissue image analysis cannot differentiate finer, potentially metal-induced tissue changes. Importantly, the tissues become more similar with an increasing LoE. We draw a conclusion about predominantly non-specific stimulation of the PT jointly by metal and polyethylene particles in non-metal-on-metal TJRs.
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Affiliation(s)
- Martin Hobza
- Department of Orthopaedics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, I. P. Pavlova 6, 779 00, Olomouc, Czech Republic
| | - David Milde
- Department of Analytical Chemistry, Faculty of Science, Palacky University Olomouc, 17. listopadu 12, 771 46 Olomouc, Czech Republic
| | - Zuzana Slobodova
- Department of Clinical and Molecular Pathology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, Olomouc, Czech Republic
| | - Jiri Gallo
- Department of Orthopaedics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, I. P. Pavlova 6, 779 00, Olomouc, Czech Republic
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Kirchen N, Reich L, Waldstein W, Hopf T, Heller KD, Wienert S, Krenn V. [ARMD reaction patterns in knee arthroplasty : A novel hypothetical mechanism: hingiosis]. DER ORTHOPADE 2020; 49:183-189. [PMID: 31919555 DOI: 10.1007/s00132-019-03776-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are case descriptions of pronounced peri-implant inflammatory reactions and necrosis in non-infectious knee joint replacements with metal-polyethylene pairing. OBJECTIVES Due to the histopathological similarities to the dysfunctional metal-on-metal (MoM) hip joint replacement, MoM-like reactions in knee joint arthroplasty ("ARMD-KEP") are proposed and a histopathological comparison is made. MATERIALS AND METHODS This analysis evaluates five cases of "ARMD-KEP" using: (1) the SLIM consensus classification, (2) the particle algorithm, (3) the CD3 focus score and (4) the AVAL score. The comparison groups consist of 11 adverse cases of MoM hip and 20 cases of knee joint arthroplasty without adverse reaction. RESULTS The ARMD-KEP cases were identified as SLIM type VI. Their median ALVAL score was 10. The CD3 focus score confirmed an adverse reaction. Particle corrosion was found in two of five cases. CONCLUSIONS This data indicates that, in rare cases, an adverse MoM-like reaction may be present in knee replacements, with inflammatory and immunological expression similar to that of the adverse MoM reaction in the hip. The pathomechanisms can be discussed as follows: (1) secondary metal-metal contact, (2) dysfunctional loading of the coupling mechanism and (3) corrosion of the metal components. Much like trunnionosis in the hip, the term "hingiosis" is proposed for corrosion phenomena in dysfunctional conditions of coupled knee endoprosthetic systems.
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Affiliation(s)
- Niklas Kirchen
- MVZ für Histologie, Zytologie und Molekulare Diagnostik Trier, Max-Planck-Straße 5, 54296, Trier, Deutschland.
| | - Lars Reich
- Universität Klagenfurt, Klagenfurt, Österreich
| | - Wenzel Waldstein
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Wien, Österreich
| | - Thomas Hopf
- Krankenhaus der Barmherzigen Brüder Trier, Trier, Deutschland
| | | | | | - Veit Krenn
- MVZ für Histologie, Zytologie und Molekulare Diagnostik Trier, Max-Planck-Straße 5, 54296, Trier, Deutschland
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Thomas P, Summer B, Thyssen JP. Orthopedic Implants. Contact Dermatitis 2020. [DOI: 10.1007/978-3-319-72451-5_80-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Schultzel M, Klein CM, Demirjian M, Blout C, Itamura JM. Incidence of Metal Hypersensitivity in Orthopedic Surgical Patients Who Self-Report Hypersensitivity History. Perm J 2019; 24:19.091. [PMID: 31852052 DOI: 10.7812/tpp/19.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Metallic implants are integral to the practice of orthopedic surgery. Delayed-onset T-cell-mediated metal hypersensitivity (diagnosed by patch testing) is reported in 10% to 17% of the general population. Inconclusive evidence exists about the role of metal hypersensitivity in persistently painful or aseptic loosening of arthroplasties. Literature suggests that preoperative patch testing may influence surgical practice. OBJECTIVE To determine the incidence of metal hypersensitivity in orthopedic surgical patients who self-report hypersensitivity and to characterize which metals are most commonly implicated. METHODS A retrospective chart review of patients from a single surgeon's practice was conducted during a 1-year period. All patients were questioned about metal hypersensitivity history; all patients who responded affirmatively were sent for patch testing for specific metals. RESULTS Only 41 (4.9%) of 840 patients self-reported any metal hypersensitivity. Of these, 34 (83%) were patch-test positive to 1 or more metals. There were 27 whose test results were positive for nickel, 4 each to cobalt or gold thiosulfate, and 1 each to tin or titanium. Seven patients had positive results to multiple metals, all of whom were also nickel hypersensitive. Six patients had metal orthopedic implants before patch testing, and 4 (67%) tested positively to a metal in their implant. CONCLUSION Metal hypersensitivity can be concerning for treating surgeons and patients. Greater awareness of a history to hypersensitivity may prevent patient exposure to implants containing metals that may cause hypersensitivity. Non-metal-containing or nonreactive metal implants are an option for patients in whom metal hypersensitivity is suspected or confirmed.
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Affiliation(s)
- Mark Schultzel
- Southern California Permanente Medical Group, Orthopedic Medical Group of San Diego, Synergy Orthopedic Specialists Medical Group, San Diego
| | - Christopher M Klein
- Kerlan-Jobe Orthopaedic Clinic, White Memorial Medical Center, Cedars-Sinai Medical Center, Keck School of Medicine, Los Angeles, CA
| | - Marine Demirjian
- Department of Allergy and Immunology, University of California, Los Angeles
| | - Colin Blout
- Kerlan-Jobe Orthopaedic Clinic, White Memorial Medical Center, Cedars-Sinai Medical Center, Keck School of Medicine, Los Angeles, CA
| | - John M Itamura
- Kerlan-Jobe Orthopaedic Clinic, White Memorial Medical Center, Cedars-Sinai Medical Center, Keck School of Medicine, Los Angeles, CA
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Elsheikh MFH, Gul R. Femoral head disengagement from Accolade femoral stem in MOM Arthroplasty: a case study and literature review. SICOT J 2019; 5:30. [PMID: 31430251 PMCID: PMC6701877 DOI: 10.1051/sicotj/2019030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/19/2019] [Indexed: 11/14/2022] Open
Abstract
Background: Metal on Metal Hip arthroplasty was commonly used until the last decade. However Hip Arthroplasty registries of many countries showed increased revision rates of MOM Hips – these high rates of revision caused by trunnionosis, adverse tissue reactions (ALTRs) and Pseudotumor formation. The Case: Our Case is 73 years old gentleman who had left MOM THR in 2008, and was doing fine till the beginning of 2018 when his left leg stuck while getting out of the car. Despite he heard the pop and his leg was shortened and externally rotated, but he was still walking on it for a while. On reviewing him in our orthopedic clinic and after getting the CT-scan showed that he had dislocated femoral head from the stem.
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Affiliation(s)
- Mohamed F H Elsheikh
- Department of Trauma and Orthopaedic, Cork University Hospital, Wilton, Cork, Republic of Ireland
| | - Rehan Gul
- Department of Trauma and Orthopaedic, Cork University Hospital, Wilton, Cork, Republic of Ireland
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Reito A, Lehtovirta L, Parkkinen J, Eskelinen A. Histopathological patterns seen around failed metal‐on‐metal hip replacements: Cluster and latent class analysis of patterns of failure. J Biomed Mater Res B Appl Biomater 2019; 108:1085-1096. [DOI: 10.1002/jbm.b.34460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/20/2019] [Accepted: 07/13/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Aleksi Reito
- Coxa Hospital for Joint Replacement Tampere Finland
| | - Lari Lehtovirta
- Coxa Hospital for Joint Replacement Tampere Finland
- School of Medicine, Tampere University Tampere Finland
| | - Jyrki Parkkinen
- Coxa Hospital for Joint Replacement Tampere Finland
- Fimlab Laboratories Tampere Finland
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Vogel D, Liebelt M, Kalkowsky F, Oberbach T, Delfosse D, Bader R. Mechanical and numerical characterization of ceramic femoral components for hip resurfacing arthroplasty. Proc Inst Mech Eng H 2019; 233:883-891. [DOI: 10.1177/0954411919855296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hip resurfacing arthroplasty may have distinct advantages for young and active patients, but large metal-on-metal bearings can be associated with increased wear, adverse tissue reactions and higher rate of implant loosening. Ceramic wear couples are a commonly used alternative to metals and therefore might be an alternative for hip resurfacing arthroplastys. The aim of this study was to evaluate the mechanical strength of femoral components made of an alumina-toughened zirconia composite by means of experimental testing and finite element analysis. For the mechanical characterization, ceramic femoral components (Ø: 48 mm) were tested under compression loading experimentally until fracture occurred or a maximum load of 85 kN was obtained. The femoral components were either loaded against a ceramic cup or a copper ring (outer diameter Ø: 7.0 mm). In addition, the complex geometry of the ceramic femoral component was simplified, and only the stem was loaded in a cantilever test until fracture. In addition, the fracture tests were numerically simulated to investigate the influence of additional loading conditions and geometric parameters, which were not experimentally tested. The experimental data were used for validation of the finite element analysis. None of the tested ceramic femoral components fractured at a compression load of 85 kN when they were loaded against a ceramic cup at an inclination angle of 45°. When the femoral components were loaded against a copper ring, the femoral components fractured at 29.9 kN at a testing angle of 45°. The fracture load was reduced when an angle of 30° and increased when an angle of 60° was simulated. Using an experimental cantilever test, the stem of the femoral component fractured at 1124.0 N. When the stem length was increased or the diameter was reduced by 10% in the finite element analysis, the fracture load was reduced. Decreasing the length or increasing the diameter led to an increase of the fracture load. The strongest influence was found for the reduction of the transition radius of the stem, with a decrease of the fracture load up to 27.2%. The analyzed femoral components made of alumina-toughened zirconia (ATZ) showed sufficient mechanical capability to withstand high loadings during unfavorable loading conditions. However, further biomechanical and tribological investigations are required before clinical application.
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Affiliation(s)
- Danny Vogel
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| | | | - Florian Kalkowsky
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| | | | | | - Rainer Bader
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
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Lehtovirta L, Reito A, Lainiala O, Parkkinen J, Hothi H, Henckel J, Hart A, Eskelinen A. Host-specific factors affect the pathogenesis of adverse reaction to metal debris. BMC Musculoskelet Disord 2019; 20:195. [PMID: 31054584 PMCID: PMC6499989 DOI: 10.1186/s12891-019-2578-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/16/2019] [Indexed: 02/08/2023] Open
Abstract
Background Adverse Reaction to Metal Debris (ARMD) is a major reason for revision surgeries in patients with metal-on-metal (MoM) hip replacements. Most failures are related to excessively wearing implant producing harmful metal debris (extrinsic factor). As ARMD may also occur in patients with low-wearing implants, it has been suggested that there are differences in host-specific intrinsic factors contributing to the development of ARMD. However, there are no studies that have directly assessed whether the development of ARMD is actually affected by these intrinsic factors. Methods We included all 29 patients (out of 33 patients) with sufficient data who had undergone bilateral revision of ASR MoM hips (58 hips) at our institution. Samples of the inflamed synovia and/or pseudotumour were obtained perioperatively and sent to histopathological analysis. Total wear volumes of the implants were assessed. Patients underwent MARS-MRI imaging of the hips preoperatively. Histological findings, imaging findings and total wear volumes between the hips of each patient were compared. Results The difference in wear volume between the hips was clinically and statistically significant (median difference 15.35 mm3, range 1 to 39 mm3, IQR 6 to 23 mm3) (p < 0.001). The median ratio of total wear volume between the hips was 2.0 (range 1.09 to 10.0, IQR 1.67 to 3.72). In majority of the histological features and in presence of pseudotumour, there were no differences between the left and right hip of each patient (p > 0.05 for all comparisons). These features included macrophage sheet thickness, perivascular lymphocyte cuff thickness, presence of plasma cells, presence of diffuse lymphocytic infiltration and presence of germinal centers. Conclusions Despite the significantly differing amounts of wear (extrinsic factor) seen between the sides, majority of the histological findings were similar in both hips and the presence of pseudotumour was symmetrical in most hips. As a direct consequence, it follows that there must be intrinsic factors which contribute to the symmetry of the findings, ie. the pathogenesis of ARMD, on individual level. This has been hypothesized in the literature but no studies have been conducted to confirm the hypothesis. Further, as the threshold of metal debris needed to develop ARMD appears to be largely variable based on the previous literature, it is likely that there are between-patient differences in these intrinsic factors, ie. the host response to metal debris is individual. Electronic supplementary material The online version of this article (10.1186/s12891-019-2578-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lari Lehtovirta
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland.,Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Tampere, Finland
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Langton DJ, Natu S, Harrington CF, Bowsher JG, Nargol AVF. Is the synovial fluid cobalt-to-chromium ratio related to the serum partitioning of metal debris following metal-on-metal hip arthroplasty? Bone Joint Res 2019; 8:146-155. [PMID: 30997040 PMCID: PMC6444018 DOI: 10.1302/2046-3758.83.bjr-2018-0049.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives We investigated the reliability of the cobalt-chromium (CoCr) synovial joint fluid ratio (JFR) in identifying the presence of a severe aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) response and/or suboptimal taper performance (SOTP) following metal-on-metal (MoM) hip arthroplasty. We then examined the possibility that the CoCr JFR may influence the serum partitioning of Co and Cr. Methods For part A, we included all revision surgeries carried out at our unit with the relevant data, including volumetric wear analysis, joint fluid (JF) Co and Cr concentrations, and ALVAL grade (n = 315). Receiver operating characteristic curves were constructed to assess the reliability of the CoCr JFR in identifying severe ALVAL and/or SOTP. For part B, we included only patients with unilateral prostheses who had given matched serum and whole blood samples for Co and Cr analysis (n = 155). Multiple regression was used to examine the influence of JF concentrations on the serum partitioning of Co and Cr in the blood. Results A CoCr JFR > 1 showed a specificity of 83% (77% to 88%) and sensitivity of 63% (55% to 70%) for the detection of severe ALVAL and/or SOTP. In patients with CoCr JFRs > 1, the median blood Cr to serum Cr ratio was 0.99, compared with 0.71 in patients with CoCr JFRs < 1 (p < 0.001). Regression analysis demonstrated that the blood Cr to serum Cr value was positively associated with the JF Co concentration (p = 0.011) and inversely related to the JF Cr concentration (p < 0.001). Conclusion Elevations in CoCr JFRs are associated with adverse biological (severe ALVAL) or tribocorrosive processes (SOTP). Comparison of serum Cr with blood Cr concentrations may be a useful additional clinical tool to help to identify these conditions.Cite this article: D. J. Langton, S. Natu, C. F. Harrington, J. G. Bowsher, A. V. F. Nargol. Is the synovial fluid cobalt-to-chromium ratio related to the serum partitioning of metal debris following metal-on-metal hip arthroplasty? Bone Joint Res 2019;8:146-155. DOI: 10.1302/2046-3758.83.BJR-2018-0049.R1.
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Affiliation(s)
- D J Langton
- Northern Retrieval Registry, The Biosphere, Newcastle Helix, Newcastle upon Tyne, UK
| | - S Natu
- University Hospital of North Tees, Stockton-on-Tees, UK
| | - C F Harrington
- Supra-Regional Assay Service (SAS), Trace Element Centre, Guildford, UK
| | - J G Bowsher
- Food and Drugs Administration, Silver Spring, Maryland, USA
| | - A V F Nargol
- University Hospital of North Tees, Stockton-on-Tees, UK
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Kovochich M, Finley BL, Novick R, Monnot AD, Donovan E, Unice KM, Fung ES, Fung D, Paustenbach DJ. Understanding outcomes and toxicological aspects of second generation metal-on-metal hip implants: a state-of-the-art review. Crit Rev Toxicol 2019; 48:853-901. [DOI: 10.1080/10408444.2018.1563048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Hallab NJ, Samelko L, Hammond D. The Inflammatory Effects of Breast Implant Particulate Shedding: Comparison With Orthopedic Implants. Aesthet Surg J 2019; 39:S36-S48. [PMID: 30715176 PMCID: PMC6355107 DOI: 10.1093/asj/sjy335] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Currently, there is a dearth of information regarding the degree of particle shedding from breast implants (BIs) and what are the general biological consequences of BI debris. Thus, it is unclear to what degree BI debris compromises the long-term biological performance of BIs. For orthopedic implants, it is well established that the severity of biological reactivity to implant debris governs long-term clinical performance. Orthopedic implant particulate debris is generally in the range of 0.01 to 100 μm in diameter. Implant debris-induced bioreactivity/inflammation is mostly a peri-implant phenomenon caused by local innate immune cells (eg, macrophages) that produce proinflammatory cytokines such as tumor necrosis factor-α, interleukin-1β, interleukin-6, and prostaglandin 2 (PGE2). In orthopedics, there have been few systemic concerns associated with polymeric implant debris (like silicone) other than documented dissemination to remote organs (eg, liver, spleen, etc.) with no known associated pathogenicity. This is not true of metal implant debris where normal (well-functioning) implants can induce systemic reactions such as delayed type hypersensitivity. Diagnostic analysis of orthopedic tissues has focused on innate (macrophage mediated) and adaptive (lymphocyte-mediated hypersensitivity) immune responses. Orthopedic implant debris-associated lymphocyte cancers have not been reported in over 40 years of orthopedic literature. Adaptive immune responses such as hypersensitivity reactions to orthopedic implant debris have been dominated by certain implant types that produce specific kinds of debris (eg, metal-on-metal total joint prostheses). Orthopedic hypersensitivity responses and atypical BI bioreactivity such as BI-associated anaplastic large cell lymphoma share crossover markers for diagnosis. Differentiating normal innate immune reactivity to particles from anaplastic large cell lymphoma reactions from delayed type hypersensitivity reactions to BI-associated implant debris remains unclear but vital to patients and surgeons.
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Affiliation(s)
- Nadim James Hallab
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Lauryn Samelko
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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Transition from metal-DTH resistance to susceptibility is facilitated by NLRP3 inflammasome signaling induced Th17 reactivity: Implications for orthopedic implants. PLoS One 2019; 14:e0210336. [PMID: 30653583 PMCID: PMC6336398 DOI: 10.1371/journal.pone.0210336] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022] Open
Abstract
Metal hypersensitivity has been recognized as an adverse biologic reaction that can compromise total joint arthroplasty (TJA) performance. However, the etiology of metal hypersensitivity responses in TJAs remains unclear. Metal implant debris is known to act as a danger signal that drives NLRP3 inflammasome activation. It remains unknown if implant debris induced inflammasome activation regulates T cell lineage in TJA metal hypersensitivity responses. In this study, we show both in vivo and in vitro that the pathogenesis of metal hypersensitivity responses to implant debris are largely dependent on activation of the inflammasome/caspase-1 pathway and subsequent production of IL-17A/F by CD4+ T cells. Inhibiting either the inflammasome pathway or IL-17A bioactivity in vivo and in vitro (in vivo using NLRP3 and Caspase-1 deficient mice or in vitro using blocking agents such as Capase-1 inhibitor, IL-1Ra and anti-IL-17A), significantly (p<0.05) mitigated metal-DTH paw inflammation as well as lymphocyte cytokine (IFN-γ and IL-17) and proliferation responses in metal-sensitized mice and primary human PBMCs. This study provides mechanistic insight into how in vivo exposure to orthopedic implant debris, and metals in general, elicits NLRP3 inflammasome activation that mediates the generation of IL-17A/F producing CD4+ T cells, leading to metal-delayed type hypersensitivity reactions.
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Garfinkel JH, Gladnick BP, Pachter CS, Cochrane NH, Romness DW. Perioperative factors associated with increased length of stay after revision of metal-on-metal total hip arthroplasty. J Orthop 2019; 16:109-112. [PMID: 30723360 DOI: 10.1016/j.jor.2019.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/08/2019] [Indexed: 12/12/2022] Open
Abstract
Objective To investigate patient factors influencing length-of-stay (LOS) after revision metal-on-metal (MoM) total hip arthroplasty (THA). Methods We reviewed 23 hips undergoing revision of a MoM THA with minimum 2-year follow-up. A multiple linear regression was calculated to predict LOS using multiple variables. Results Average length of stay (LOS) was 2.1 days. Multiple linear regression analysis identified a significant correlation between presence of an abductor injury (beta = 0.8886; p < 0.0001), patient age (beta = -0.4452, p = 0.0083), and pre-revision head size (beta = 0.4082; p = 0.0172) with LOS (R2 = 0.6351, p = 0.0002). Conclusion Patients with abductor injury, larger femoral heads, and younger age are at risk for longer LOS.
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Affiliation(s)
- Jonathan H Garfinkel
- Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC, 20007, USA
| | - Brian P Gladnick
- W.B. Carrell Memorial Clinic, Adult Hip and Knee Reconstruction, 9301 N. Central Expressway, Suite 500, Dallas, TX, 75231, USA
| | - Cole S Pachter
- OrthoVirginia, Adult Hip and Knee Reconstruction, 1635 N. George Mason Drive, Suite 310, Arlington, VA, 22205, USA
| | - Niall H Cochrane
- Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC, 20007, USA
| | - David W Romness
- Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC, 20007, USA.,OrthoVirginia, Adult Hip and Knee Reconstruction, 1635 N. George Mason Drive, Suite 310, Arlington, VA, 22205, USA
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Norman TL, Denen JE, Land AJ, Kienitz DM, Fehring TA. Taper-Trunnion Interface Stress Varies Significantly With Head Size and Activity. J Arthroplasty 2019; 34:157-162. [PMID: 30318251 DOI: 10.1016/j.arth.2018.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/29/2018] [Accepted: 09/07/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total hip arthroplasty is performed with modular parts. Either a metal or ceramic ball is fastened to the trunnion of a femoral stem via a Morse taper. This implant scenario has been successful. However, recently larger (36 mm or greater) metal heads have become more popular as a means to reduce the incidence of hip joint dislocation. Today, a number of clinical failures have occurred due to mechanically assisted crevice corrosion at the head (taper) stem (trunnion) interface necessitating revision surgery. The objective of this research is to investigate how trunnion stress varies with head size, and how taper-trunnion geometric parameters including horizontal lever arm (HLA), taper engagement level, and a new parameter called trunnion load offset affect trunnion stresses. We hypothesized that trunnion stress may increase with increasing head size and HLA. METHODS This hypothesis was tested by conducting finite element analysis of a titanium hip stem and 4 commercially available cobalt-chromium femoral heads subjected to 4 different moderate to severe physiological loading conditions. RESULTS Results showed that trunnion stress increases with increasing head size, increased HLA, and trunnion load offset. It was also found that under certain load cases the trunnion stresses get exceptionally high, especially for the larger head sizes. CONCLUSION This study suggests trying to avoid larger femoral head sizes that may result in higher implant stresses under certain loading conditions.
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Affiliation(s)
- Timothy L Norman
- School of Engineering and Computer Science, Cedarville University, Cedarville, OH
| | - Jordan E Denen
- School of Engineering and Computer Science, Cedarville University, Cedarville, OH
| | - Austin J Land
- School of Engineering and Computer Science, Cedarville University, Cedarville, OH
| | - Devan M Kienitz
- School of Engineering and Computer Science, Cedarville University, Cedarville, OH
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Differential toxicity of processed and non-processed states of CoCrMo degradation products generated from a hip simulator on neural cells. Nanotoxicology 2018; 12:941-956. [PMID: 30251573 DOI: 10.1080/17435390.2018.1498929] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Physico-chemical characteristics of the CoCrMo degradation products have played an important role in cytotoxicity and clinical complications on the orthopedic patients who have metal implants. Previous studies have limited reflection on the physicochemical characteristics of the degradation products generated in vivo, which are very different from individual metal particles and/or ions obtained from different commercial sources. In this study, we aimed to understand the differences in toxicity induced by the degradation products in as-synthesized form as well as those obtained after post-processing. The degradation products were generated using a hip-simulator by maintaining physiological conditions closer to in vivo and separated into two batches, one with processing by washing and drying called processed degradation products (PDP) and another batch as 'as-synthesized' degradation product (DP). We studied the dose-dependent toxicity response by neural cells derived from induced pluripotent stem cells. The results of the study show that as-synthesized DPs are more toxic to neural cells even at lower concentrations studied with evident low TC50 (1-5 μg/ml) concentrations compared to PDP (25 μg/ml). Flow cytometric analysis showed a significant (p<.01) increase in uptake of the particles after 24 h and corresponding ROS production in DP-treated cells. RT-PCR analysis of oxidative specific gene expression showed, elevated mRNA levels of NADPH oxidase-1, nuclear transcription factor, superoxide dismutase-2 and glutaredoxin-2 in DP-treated cells after 6 h. The results of the study provided a clear evidence of the differential response of neural cells on the degradation products as a function of concentrations and their chemical nature.
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Midterm results of Magnum large head metal-on-metal total hip arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2018.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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McCarthy EM, Floyd H, Addison O, Zhang ZJ, Oppenheimer PG, Grover LM. Influence of Cobalt Ions on Collagen Gel Formation and Their Interaction with Osteoblasts. ACS OMEGA 2018; 3:10129-10138. [PMID: 30221240 PMCID: PMC6130901 DOI: 10.1021/acsomega.8b01048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/18/2018] [Indexed: 05/03/2023]
Abstract
Metals on metal implants have long been used in arthroplasties because of their robustness and low dislocation rate. Several relatively low-corrosion metals have been used in arthroplasty, including 316L stainless steel, titanium, and cobalt-chromium-molybdenum alloy. Debris from these implants, however, has been found to cause inflammatory responses leading to unexpected failure rates approaching 10% 7 years surgery. Safety assessment of these materials traditionally relies on the use of simple two-dimensional assays, where cells are grown on the surface of the material over a relatively short time frame. It is now well-known that the composition and stiffness of the extracellular matrix (ECM) have a critical effect on cell function. In this work, we have evaluated how cobalt ions influence the assembly of type I collagen, the principle component of the ECM in bone. We found that cobalt had a significant effect on collagen matrix formation, and its presence results in local variations in collagen density. This increase in heterogeneity causes an increase in localized mechanical properties but a decrease in the bulk stiffness of the material. Moreover, when collagen matrices contained cobalt ions, there was a significant change in how the cells interacted with the collagen matrix. Fluorescence images and biological assays showed a decrease in cell proliferation and viability with an increase in cobalt concentration. We present evidence that the cobalt ion complex interacts with the hydroxyl group present in the carboxylic terminal of the collagen fibril, preventing crucial stabilizing bonds within collagen formation. This demonstrates that the currently accepted toxicity assays are poor predictors of the longer-term biological performance of a material.
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Affiliation(s)
- Emma M. McCarthy
- Physical
Sciences for Health, School of Chemistry, Physical Sciences of Imaging in
the Biomedical Sciences, School of Chemistry, Department of BioChemical Engineering,
School of Chemical Engineering, and School of Dentistry, University of Birmingham, Edgbaston, B15 2TT Birmingham, U.K.
- E-mail: (E.M.M.)
| | - Hayley Floyd
- Physical
Sciences for Health, School of Chemistry, Physical Sciences of Imaging in
the Biomedical Sciences, School of Chemistry, Department of BioChemical Engineering,
School of Chemical Engineering, and School of Dentistry, University of Birmingham, Edgbaston, B15 2TT Birmingham, U.K.
| | - Owen Addison
- Physical
Sciences for Health, School of Chemistry, Physical Sciences of Imaging in
the Biomedical Sciences, School of Chemistry, Department of BioChemical Engineering,
School of Chemical Engineering, and School of Dentistry, University of Birmingham, Edgbaston, B15 2TT Birmingham, U.K.
| | - Zhenyu J. Zhang
- Physical
Sciences for Health, School of Chemistry, Physical Sciences of Imaging in
the Biomedical Sciences, School of Chemistry, Department of BioChemical Engineering,
School of Chemical Engineering, and School of Dentistry, University of Birmingham, Edgbaston, B15 2TT Birmingham, U.K.
| | - Pola Goldberg Oppenheimer
- Physical
Sciences for Health, School of Chemistry, Physical Sciences of Imaging in
the Biomedical Sciences, School of Chemistry, Department of BioChemical Engineering,
School of Chemical Engineering, and School of Dentistry, University of Birmingham, Edgbaston, B15 2TT Birmingham, U.K.
| | - Liam M. Grover
- Physical
Sciences for Health, School of Chemistry, Physical Sciences of Imaging in
the Biomedical Sciences, School of Chemistry, Department of BioChemical Engineering,
School of Chemical Engineering, and School of Dentistry, University of Birmingham, Edgbaston, B15 2TT Birmingham, U.K.
- E-mail: (L.M.G.)
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Langton DJ, Sidaginamale RP, Joyce TJ, Bowsher JG, Holland JP, Deehan D, Nargol AVF, Natu S. Aseptic lymphocyte-dominated vasculitis-associated lesions are related to changes in metal ion handling in the joint capsules of metal-on-metal hip arthroplasties. Bone Joint Res 2018; 7:388-396. [PMID: 30034792 PMCID: PMC6035361 DOI: 10.1302/2046-3758.76.bjr-2018-0037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objectives We have encountered patients who developed large joint fluid collections with massive elevations in chromium (Cr) and cobalt (Co) concentrations following metal-on-metal (MoM) hip arthroplasties. In some cases, retrieval analysis determined that these ion concentrations could not be explained simply by the wear rates of the components. We hypothesized that these effects may be associated with aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL). Patients and Methods We examined the influence of the ALVAL grade on synovial fluid Co and Cr concentrations following adjustment for patient and device variables, including volumetric wear rates. Initially restricting the analysis to include only patients with one MoM hip resurfacing device, we performed multiple regression analyses of prospectively collected data. We then repeated the same statistical approach using results from a larger cohort with different MoM designs, including total hip arthroplasties. Results In the resurfacing cohort (n = 76), the statistical modelling indicated that the presence of severe ALVAL and a large fluid collection were associated with greater joint fluid Co concentrations after adjustment for volumetric wear rates (p = 0.005). These findings were replicated in the mixed implant group (n = 178), where the presence of severe ALVAL and a large fluid collection were significantly associated with greater fluid Co concentrations (p < 0.001). Conclusion The development of severe ALVAL is associated with elevations in metal ion concentrations far beyond those expected from the volumetric loss from the prosthetic surfaces. This finding may aid the understanding of the sequence of events leading to soft-tissue reactions following MoM hip arthroplasties. Cite this article: D. J. Langton, R. P. Sidaginamale, T. J. Joyce, J. G. Bowsher, J. P. Holland, D. Deehan, A. V. F. Nargol, S. Natu. Aseptic lymphocyte-dominated vasculitis-associated lesions are related to changes in metal ion handling in the joint capsules of metal-on-metal hip arthroplasties. Bone Joint Res 2018;7:388–396. DOI: 10.1302/2046-3758.76.BJR-2018-0037.
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Affiliation(s)
| | | | - T J Joyce
- Newcastle University, Newcastle upon Tyne, UK
| | - J G Bowsher
- Food and Drugs Administration, Maryland, USA
| | | | - D Deehan
- Freeman Hospital, Newcastle upon Tyne, UK
| | - A V F Nargol
- University Hospital of North Tees, Stockton-on-Tees, UK
| | - S Natu
- University Hospital of North Tees, Stockton-on-Tees, UK
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Aguado-Maestro I, Cebrián Rodríguez E, Paredes Herrero E, Brunie Vegas F, Oñate Miranda M, Fernández García N, García Alonso M. Midterm results of Magnum large head metal-on-metal total hip arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018; 62:310-317. [PMID: 29903424 DOI: 10.1016/j.recot.2018.05.003] [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: 08/16/2017] [Revised: 04/05/2018] [Accepted: 05/03/2018] [Indexed: 10/14/2022] Open
Abstract
OBJECTIVES We present the results of the prospective follow up of a sample of large head metal-metal total hip arthroplasty obtained after the safety alert regarding a higher incidence of revision of these implants. MATERIAL AND METHODS All patients implanted with the Recap-M2a-Magnum cup between 2008 and 2011 were included. They were prospectively reviewed recording Harris Hip Score, clinical symptoms of chromium or cobalt intoxication. Serum levels of these ions were requested as well as X-Rays and ultrasonography. An MRI was performed in the cases of positive ultrasonography. RESULTS Twenty-six males with a mean age of 48.54 years [32-62, SD: 7.18] were included. An anterolateral approach and Bi-Metric (7) and F-40 (19) stems were used. Cephalic diameters ranged 42-52 (mode: 46) and the mean cup inclination was 39.35° [21-59°, SD: 9.78]. During follow-up (7.3 years [5.9-9.4; SD: .78]), 3 patients (11.5%) underwent revision (2 cases aseptic loosening, 1 pseudotumour). Mean time until revision was 5.4 years [3.1-8.0; SD: 2.48]. The accumulated survival probability was 88.5% (95% CI 76.3-100%). Harris Hip Score was 94.47 [66.5-100; SD: 8.94] and the patients showed no metallic intoxication symptoms. The levels of chromium were 1.88 mcg/dl [0.6-3.9] and cobalt 1,74 mcg/dl [0.5-5,6]. One pseudotumour was found in an asymptomatic patient, and small amounts of periarticular liquid were found in 5 patients (19.2%) DISCUSSION AND CONCLUSIONS: High revision rates are still found when follow up is extended due to aseptic loosening and pseudotumour formation. MRI might not be the most adequate test to study the complications of these prostheses.
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Affiliation(s)
- I Aguado-Maestro
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario del Río Hortega, Valladolid, España.
| | - E Cebrián Rodríguez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario del Río Hortega, Valladolid, España
| | - E Paredes Herrero
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario del Río Hortega, Valladolid, España
| | - F Brunie Vegas
- Servicio de Radiología, Hospital Universitario del Río Hortega, Valladolid, España
| | - M Oñate Miranda
- Servicio de Radiología, Hospital Universitario del Río Hortega, Valladolid, España
| | - N Fernández García
- Servicio de Análisis Clínicos, Hospital Universitario del Río Hortega, Valladolid, España
| | - M García Alonso
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario del Río Hortega, Valladolid, España
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Heckmann ND, Sivasundaram L, Stefl MD, Kang HP, Basler ET, Lieberman JR. Total Hip Arthroplasty Bearing Surface Trends in the United States From 2007 to 2014: The Rise of Ceramic on Polyethylene. J Arthroplasty 2018; 33:1757-1763.e1. [PMID: 29429883 DOI: 10.1016/j.arth.2017.12.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/23/2017] [Accepted: 12/28/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Wear of the bearing surface is a critical element in determining the longevity of a total hip arthroplasty (THA). Over the past decade, concerns related to modern metal-on-metal (MoM) bearings and corrosion at the femoral head-neck interface have influenced surgeon selection of bearing surfaces. The purpose of this study is to analyze trends in THA bearing surface selection from 2007 through 2014 using a large national database. METHODS The Nationwide Inpatient Sample database was used to extract bearing surface data from patients who underwent a primary THA between 2007 and 2014. Patients were grouped by bearing surface type: metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), MoM, and ceramic-on-ceramic (CoC) bearings. Descriptive statistics were employed to describe trends. Univariate and multivariate analyses were performed to identify differences between bearing surface groups. RESULTS During the study period, 2,460,640 THA discharges were identified, of which 1,059,825 (43.1%) had bearing surface data. A total of 496,713 (46.9%) MoP, 307,907 (29.1%) CoP, 210,381 (19.9%) MoM, and 44,823 (4.2%) CoC cases were identified. MoM utilization peaked in 2008 representing 40.1% of THAs implanted that year and steadily declined to 4.0% in 2014. From 2007 to 2014, the use of CoP bearing surfaces increased from 11.1% of cases in 2007 to 50.8% of cases in 2014. In 2014, CoP utilization surpassed MoP which represented 42.1% of bearing surfaces that year. CONCLUSION During the study period, MoM bearing surfaces decreased precipitously, while CoP surpassed MoP as the most popular bearing surface used in a THA.
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Affiliation(s)
- Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | | | - Michael D Stefl
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Hyunwoo Paco Kang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Eric T Basler
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
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de Steiger R, Peng A, Lewis P, Graves S. What Is the Long-term Survival for Primary THA With Small-head Metal-on-metal Bearings? Clin Orthop Relat Res 2018; 476:1231-1237. [PMID: 29432270 PMCID: PMC6263567 DOI: 10.1007/s11999.0000000000000209] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Large-head metal-on-metal (MoM) bearing hip replacements have been shown to have a much higher rate of revision than other bearing surfaces. However, small-head (≤ 32 mm) MoM bearing surfaces have been in use for many years with several reports of satisfactory mid- to long-term survivorship. It is unclear whether the long-term survival of small-head MoM devices will continue to be satisfactory or whether the same concerns seen with the large-head MoM devices will ultimately become more prevalent. QUESTIONS/PURPOSES We analyzed a large national registry to ask: (1) What is the 15-year Kaplan-Meier survivorship of primary conventional THA using small-head (≤ 32 mm) MoM bearing surfaces compared with large-head MoM bearing surfaces in primary THA? (2) Is there an increased rate of revision for adverse reaction to metal debris (ARMD) in this group of patients over time? METHODS The Australian Orthopaedic Association National Joint Replacement Registry longitudinally maintains data on all primary and revision joint arthroplasties with nearly 100% capture. We analyzed all conventional primary THAs performed from Registry inception in September 1999 until December 31, 2015, in patients with a diagnosis of osteoarthritis and using MoM bearing surfaces ≤ 32 mm in diameter, defined as small-head MoM. The study group included 4838 primary THA with ≤ 32-mm MoM bearing surfaces. There were 2506 (51.8%) male patients and the median age of patients undergoing THA with a small-head MoM bearing surface was 64 years (range, 20-92 years of age). The outcome measure was the cumulative percent revision defined as the time to first revision using Kaplan-Meier estimates of survivorship at 15 years; reasons for revision and type of revision were also examined. We specifically investigated whether there was an increased risk of revision for ARMD in this MoM group compared with all other bearing surfaces. We compared these results with large-head MoM THAs (femoral head size > 32 mm). RESULTS The cumulative percent revision for small-head MoM designs at 15 years was 8.5% (95% confidence interval [CI], 7.3-9.9). The cumulative percent revision for large-head MoM at 14 years was 27.4% (95% CI, 24.8-30.2). Prostheses with a large-head MoM articulation have a higher rate of revision than small-head MoM bearing surfaces (hazard ratio after 6 years, 5.14; 95% CI, 4.1-6.5; p < 0.001). Over time, there was a gradual increase in the diagnosis of ARMD for small-head MoM and the cumulative incidence of revision for ARMD was 0.8% at 15 years. CONCLUSIONS Despite survival that is substantially greater than that of large-head MoM THAs, there has been a marked decrease in the use of small-head MoM designs in our registry. Although the reasons for this are likely multifactorial, the increasing incidence of revisions for ARMD among small-head MoM THAs is concerning. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Richard de Steiger
- R. de Steiger, Department of Surgery, Epworth Healthcare, University of Melbourne, Richmond, Victoria, Australia A. Peng, South Australian Health and Medical Research Institute, Adelaide, Australia P. Lewis, S. Graves, Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, Australia This work was performed at the Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
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Lehtovirta L, Reito A, Parkkinen J, Peräniemi S, Vepsäläinen J, Eskelinen A. Association between periprosthetic tissue metal content, whole blood and synovial fluid metal ion levels and histopathological findings in patients with failed metal-on-metal hip replacement. PLoS One 2018; 13:e0197614. [PMID: 29768492 PMCID: PMC5955572 DOI: 10.1371/journal.pone.0197614] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 05/04/2018] [Indexed: 02/08/2023] Open
Abstract
Adverse Reaction to Metal Debris (ARMD) is a major cause of implant failure leading to revision surgery in patients with metal-on-metal (MoM) hip arthroplasties. However, the pathogenesis and its association to implant wear are poorly understood and previous studies have yielded discrepant results. We sought to investigate the associations between histological findings, whole blood and synovial fluid metal ion concentrations and periprosthetic tissue metal concentrations in patients with MoM total hip replacements and hip resurfacings revised for ARMD. 107 hips in total were included in our study. Of these, 87 were total hip replacements and 20 were hip resurfacings, respectively. We found that whole blood, synovial fluid and periprosthetic tissue metal concentrations correlated poorly with histological findings. We suggest that the lack of a clear association between histological findings and wear measures in the present study as well as in previous studies is mostly influenced by variability in patient susceptibility. However, patients presenting with perivascular lymphocytic infiltration had lower chromium concentration in their periprosthetic tissues than patients with no perivascular lymphocytic infiltration. This may reflect the role of metal hypersensitivity in implant failure in these patients. Patients with total hip replacements evinced more necrosis and lymphocytic infiltration in their tissues than patients with hip resurfacings. This suggests that trunnion wear debris is more cytotoxic and/or immunogenic than bearing wear debris leading to higher failure rates seen in patients with total hip replacements.
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Affiliation(s)
- Lari Lehtovirta
- University of Tampere, Tampere, Finland
- Coxa Hospital for Joint Replacement, Tampere, Finland
- * E-mail:
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
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Bijukumar DR, Segu A, Souza JCM, Li X, Barba M, Mercuri LG, J Jacobs J, Mathew MT. Systemic and local toxicity of metal debris released from hip prostheses: A review of experimental approaches. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2018; 14:951-963. [PMID: 29339190 PMCID: PMC6017990 DOI: 10.1016/j.nano.2018.01.001] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 12/22/2017] [Accepted: 01/02/2018] [Indexed: 12/12/2022]
Abstract
Despite the technological improvements in orthopedic joint replacement implants, wear and corrosion products associated with the metal components of these implants may result in adverse local tissue and perhaps systemic reactions and toxicities. The current review encompasses a literature review of the local and systemic toxicity studies concerning the effect of CoCrMo wear debris released from wear and corrosion of orthopedic implants and prostheses. Release of metallic debris is mainly in the form of micro- and nano-particles, ions of different valences, and oxides composed of Co and Cr. Though these substances alter human biology, their direct effects of these substances on specific tissue types remain poorly understood. This may partially be the consequence of the multivariate research methodologies employed, leading to inconsistent reports. This review proposes the importance of developing new and more appropriate in-vitro methodologies to study the cellular responses and toxicity mediated by joint replacement wear debris in-vivo.
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Affiliation(s)
- Divya Rani Bijukumar
- Regenerative Medicine and Disability Research Lab, Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, IL, USA
| | - Abhijith Segu
- Regenerative Medicine and Disability Research Lab, Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, IL, USA
| | - Júlio C M Souza
- Center for MicroElectromechanical Systems (CMEMS-UMINHO), University of Minho, Guimaraes, Portugal
| | - XueJun Li
- Regenerative Medicine and Disability Research Lab, Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, IL, USA
| | - Mark Barba
- Regenerative Medicine and Disability Research Lab, Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, IL, USA; OrthoIllinois, Rockford, IL, USA
| | - Louis G Mercuri
- Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA
| | - Joshua J Jacobs
- Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA
| | - Mathew Thoppil Mathew
- Regenerative Medicine and Disability Research Lab, Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, IL, USA; Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA; Department of Bioengineering, University of Illinois at Chicago, IL, USA.
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Kilb BKJ, Kurmis AP, Parry M, Sherwood K, Keown P, Masri BA, Duncan CP, Garbuz DS. Frank Stinchfield Award: Identification of the At-risk Genotype for Development of Pseudotumors Around Metal-on-metal THAs. Clin Orthop Relat Res 2018; 476. [PMID: 29529651 PMCID: PMC6259707 DOI: 10.1007/s11999.0000000000000028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Once touted as the future of hip arthroplasty, metal-on-metal (MoM) bearing surfaces have fallen sharply from favor with the emergence of a strong body of evidence demonstrating unacceptably high premature implant failure rates. The previously unpredictable development of adverse local tissue reactions (ALTRs) has been a substantive contributor to this. Although the underlying pathophysiology of these so-called "pseudotumors" is now well understood, the fundamental predisposing patient risk factors have remained elusive. QUESTIONS/PURPOSES The aim of this research, as a clinical-genotype correlation analysis, was to identify specific alleles (genes) associated with the development of ALTRs in patients with in situ MoM THAs. METHODS A case-control study of patients who received a large-head, primary MoM THA between 2005 and 2008 was performed with a minimum followup of 5 years. Twenty-six patients who had undergone revision of a primary MoM THA secondary to symptomatic ALTRs were recruited. The mean timeframe from primary MoM THA to symptomatic revision was 5.5 years (range, 1-10 years). Twenty-eight control subjects were randomly selected asymptomatic patients with no evidence of ALTRs on protocol-specific screening. Baseline demographics and high-resolution genotype (human leukocyte antigen [HLA] Class II) were collected for all patients. Cohorts were similar with respect to age at the time of primary MoM THA (mean, 54.8 versus 54.9 years, p = 0.95) and serum cobalt (mean, 5.5 versus 8.5 μg/L, p = 0.09) and chromium concentrations (mean, 2.9 versus 4.2 μg/L, p = 0.27). The association between genotype and revision surgery secondary to ALTRs was determined with gender as a covariate. RESULTS The prevalence of the risk genotype was 30% (16 of 54) among the entire cohort. Adjusting for sex, the odds of revision were 6.1 times greater among patients with the risk genotype present than among patients without (95% confidence interval [CI], 1.5-25.4; p = 0.01). Among females, the specificity of the risk genotype was 1.0 (95% CIexact, 0.5-1.0; pexact = 0.03), and for males, it was 0.8 (95% CIexact, 0.6-0.9; pexact < 0.01). CONCLUSIONS The findings of this study suggest that, among patients with a primary MoM THA, allelic variation within the HLA Class II loci may be a strong, independent risk factor associated with the need for subsequent revision surgery secondary to pseudotumor formation. CLINICAL RELEVANCE Given the hypothesis-generating nature of this novel undertaking, confirmatory prospective clinical studies are required to further elucidate this correlation and to explore the clinical utility of targeted genetic screening in this specific population. This research may, however, represent a key missing piece in the puzzle that is metal ion-induced pseudotumor formation.
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Affiliation(s)
- Brett K J Kilb
- B. K. J. Kilb, A. P. Kurmis, M. Parry, B. A. Masri, C. P. Duncan, D. S., Garbuz Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada K. Sherwood, P. Keown Department of Pathology (&) Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada P. Keown, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada A. P. Kurmis, Discipline of Medical Specialties, University of Adelaide, Adelaide, SA, Australia
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