Aseptic lymphocyte-dominated vasculitis-associated lesions are related to changes in metal ion handling in the joint capsules of metal-on-metal hip arthroplasties

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.

Download Full-text

Does diametrical clearance influence the wear of Pinnacle hip implants?

Bone and Joint Research ◽

10.1302/2046-3758.98.bjr-2019-0195.r2 ◽

2020 ◽

Vol 9 (8) ◽

pp. 515-523 ◽

Cited By ~ 1

Author(s):

Sean Bergiers ◽

Harry Hothi ◽

Johann Henckel ◽

Antti Eskelinen ◽

John Skinner ◽

...

Keyword(s):

Volumetric Wear ◽

Wear Performance ◽

Wear Rates ◽

Manufacturing Tolerance ◽

Metal On Metal ◽

Hip Arthroplasties ◽

The Relationship ◽

Spearman’S Correlation ◽

Film Lubrication ◽

Fluid Film Lubrication

Aims The optimum clearance between the bearing surfaces of hip arthroplasties is unknown. Theoretically, to minimize wear, it is understood that clearances must be low enough to maintain optimal contact pressure and fluid film lubrication, while being large enough to allow lubricant recovery and reduce contact patch size. This study aimed to identify the relationship between diametrical clearance and volumetric wear, through the analysis of retrieved components. Methods A total of 81 metal-on-metal Pinnacle hips paired with 12/14 stems were included in this study. Geometrical analysis was performed on each component, using coordinate and roundness measuring machines. The relationship between their as-manufactured diametrical clearance and volumetric wear was investigated. The Mann-Whitney U test and unpaired t-test were used, in addition to calculating the non-parametric Spearman's correlation coefficient, to statistically evaluate the acquired data. Results The hips in this study were found to have had a median unworn diametrical clearance of 90.31 μm (interquartile range (IQR) 77.59 to 97.40); 32% (n = 26) were found to have been below the manufacturing tolerance. There was no correlation found between clearance and bearing (rs = -0.0004, p = 0.997) or taper (rs = 0.0048, p = 0.966) wear rates. The wear performance of hips manufactured within and below these specifications was not significantly different (bearing: p = 0.395; taper: p = 0.653). Pinnacles manufactured from 2007 onwards had a greater prevalence of bearing clearance below tolerance (p = 0.004). Conclusion The diametrical clearance of Pinnacle hips did not influence their wear performance, even when below the manufacturing tolerance. The optimum clearance for minimizing hip implant wear remains unclear. Cite this article: Bone Joint Res 2020;9(8):515–523.

Download Full-text

Influence of implant design on blood metal ion concentrations in metal-on-metal total hip replacement patients

International Orthopaedics ◽

10.1007/s00264-014-2644-z ◽

2015 ◽

Vol 39 (9) ◽

pp. 1803-1811 ◽

Cited By ~ 7

Author(s):

Gulraj S. Matharu ◽

Fiona Berryman ◽

Lesley Brash ◽

Paul B. Pynsent ◽

Ronan B. Treacy ◽

...

Keyword(s):

Total Hip Replacement ◽

Hip Replacement ◽

Metal Ion ◽

Implant Design ◽

Ion Concentrations ◽

Total Hip ◽

Metal On Metal

Download Full-text

Alternative Bearing Couples in Total Hip Replacements: Solutions for Young Patients

Hip International ◽

10.1177/112070000301302s07 ◽

2003 ◽

Vol 13 (2_suppl) ◽

pp. 31-35 ◽

Cited By ~ 3

Author(s):

J. Fisher ◽

E. Ingham ◽

M.H. Stone

Keyword(s):

Polyethylene Wear ◽

Young Patients ◽

Volumetric Wear ◽

Wear Rates ◽

Total Hip Replacements ◽

Metal On Metal ◽

Hip Replacements ◽

Gamma Irradiated ◽

Ceramic On Ceramic

There is now considerable clinical concern about the effect of polyethylene wear debris induced osteolysis in long term failure of hip replacements. This paper compares the wear of stabilised and crosslinked polyethylene to alternative hard on hard bearings. The volumetric wear rates of stabilised and moderately crosslinked polyethylene 50 to 35 mm3/million cycles were less than previously reported for historical gamma irradiated in air polyethylene, but still of a level that in the long term could cause osteolysis. The moderately crosslinked polyethylene produced less wear than non-crosslinked polyethylene, but particles were smaller and more reactive resulting in little change in the osteolytic potential. Alumina ceramic on ceramic produced substantially less wear and osteolytic potential. Metal on metal also produced less wear than polyethylene but the particles adversely influence cell viability.

Download Full-text

Blood metal ion concentrations in metal-on-metal total hip arthroplasty

European Journal of Orthopaedic Surgery & Traumatology ◽

10.1007/s00590-017-1931-y ◽

2017 ◽

Vol 27 (4) ◽

pp. 527-532 ◽

Cited By ~ 2

Author(s):

Tadahiko Ohtsuru ◽

Yuji Morita ◽

Yasuaki Murata ◽

Shuji Shimamoto ◽

Yutaro Munakata ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Hip Arthroplasty ◽

Metal Ion ◽

Ion Concentrations ◽

Total Hip ◽

Metal On Metal

Download Full-text

Can cobalt levels estimate in-vivo wear of metal-on-metal bearings used in hip arthroplasty?

Proceedings of the Institution of Mechanical Engineers Part H Journal of Engineering in Medicine ◽

10.1243/09544119jeim270 ◽

2007 ◽

Vol 221 (8) ◽

pp. 929-942 ◽

Cited By ~ 10

Author(s):

M Khan ◽

J H Kuiper ◽

J B Richardson

Keyword(s):

Clinical Studies ◽

Wear Debris ◽

Metal Ion ◽

Large Diameter ◽

Small Diameter ◽

Wear Rates ◽

Hip Simulator ◽

Metal On Metal ◽

Metal Levels

High levels of cobalt and chromium ions are detected in the blood and urine of patients with metal-on-metal (MoM) hip replacement. These elements are released as a result of wear at the bearing surfaces. Wear rates depend on a multitude of factors, which include the bearing geometry, carbon content, manufacturing processes, lubrication, speed and direction of sliding of the surfaces, pattern of loading, and orientation of the components. In-vivo wear of MoM bearings cannot be reliably measured on X-rays because no distinction can be made between the bearing surfaces. Hip simulator studies have shown that wear rates are higher during the initial bedding-in phase and subsequently drop to very low levels. Accordingly, metal ion levels would be expected to decrease with the use of the bearing, measured as implantation time following surgery. However, several clinical studies have found that metal ion levels either gradually rise or fluctuate instead of decreasing to lower levels. Moreover, hip simulator studies predict that large-diameter bearings have lower wear rates than small-diameter bearings. In clinical studies, however, metal levels in patients with large-diameter bearings are unexpectedly higher than those in patients with small-diameter bearings. As a consequence, high cobalt ion levels in patients do not necessarily imply that their MoM bearings produce much wear debris at the time that their levels were measured; it may simply be due to accumulation of wear debris from the preceding time. Exercise-related cobalt rise may overcome this limitation and give a better assessment of the current wear status of a MoM bearing surface than a measure of cobalt levels only.

Download Full-text

Blood Metal Ion Levels Have Limited Utility in the Surveillance of Asymptomatic Large-Head Metal-on-Metal Total Hip Arthroplasties

The Journal of Arthroplasty ◽

10.1016/j.arth.2017.07.015 ◽

2017 ◽

Vol 32 (12) ◽

pp. 3685-3688 ◽

Cited By ~ 9

Author(s):

Manish Kiran ◽

Catherine Armstrong ◽

Deepak Shivarathre ◽

Viju K. Peter

Keyword(s):

Metal Ion ◽

Total Hip ◽

Large Head ◽

Metal On Metal ◽

Hip Arthroplasties

Download Full-text

Does modularity of metal-on-metal hip implants increase cobalt: chromium ratio?

Hip International ◽

10.1177/1120700019873637 ◽

2019 ◽

pp. 112070001987363

Author(s):

Kevin C Ilo ◽

Karim Aboelmagd ◽

Harry S Hothi ◽

Asaad Asaad ◽

John A Skinner ◽

...

Keyword(s):

Metal Ion ◽

Hip Implants ◽

Cobalt Chromium ◽

Metal Debris ◽

Material Loss ◽

Total Hip ◽

Modular Stem ◽

Metal On Metal ◽

Hip Replacements ◽

Hip Arthroplasties

Background: Blood metal ion levels are used in the surveillance of metal-on-metal (MoM) hip implants. Modular implants contain an extra source of metal debris that may affect the ratio of metal ions in the blood. Methods: This was a retrospective study of 503 patients with hip replacements made by a single manufacturer (Smith & Nephew, Warwick, UK) with the same bearing surface. There were 54 total hip arthroplasties, 35 Birmingham Mid-Head Resections and 414 hip resurfacings. Whole blood metal ion levels and their ratios were analysed to investigate the effect of a modular junction. Results: The cobalt:chromium ratios were greater in the total hip arthroplasty group (mean 2.3:1) when compared to the resurfacings group (mean 1.3:1, p = <0.05) and Birmingham Mid-Head Resection group (mean 1.1:1, p = 0.11). Conclusions: This study demonstrated a trend for a higher cobalt:chromium ratio in patients with MoM total hip replacement that may be due to metal debris from the modular stem-head junction. Further work is required to correlate clinical data with retrieval analysis to confirm the effect of taper material loss on the cobalt:chromium ratio.

Download Full-text

Do cobalt or chromium accumulate in metal-on-metal hip arthroplasty patients who have mild, moderate, or severe renal insufficiency?

The Bone & Joint Journal ◽

10.1302/0301-620x.103b7.bjj-2020-0836.r2 ◽

2021 ◽

Vol 103-B (7) ◽

pp. 1231-1237

Author(s):

Eveliina Manninen ◽

Olli Lainiala ◽

Mari Karsikas ◽

Aleksi Reito ◽

Pyry Jämsä ◽

...

Keyword(s):

Renal Insufficiency ◽

Hip Arthroplasty ◽

Whole Blood ◽

Metal Ion ◽

Inverse Association ◽

Severe Renal Insufficiency ◽

Metal On Metal ◽

The Usa ◽

Hip Arthroplasties

Aims To find out if there is an inverse association between estimated glomerular filtration rate (eGFR) and whole blood cobalt (Co) and chromium (Cr) levels in patients with metal-on-metal (MoM) hip arthroplasties and renal insufficiency, suggesting that renal insufficiency could cause accumulation of Co and Cr in blood. Methods Out of 2,520 patients with 3,013 MoM hip arthroplasties, we identified 1,244 patients with whole blood Co, Cr, and creatinine measured within no more than a one-year interval. We analyzed the correlation of blood metal ion levels and eGFR to identify a potential trend of accumulating Co or Cr with decreasing eGFR. Results Of the 1,244 patients, 112 had normal renal function (eGFR > 90 ml/min/1.73 m2), 715 had mild renal insufficiency (eGFR 60 to 89), 384 had moderate renal insufficiency (eGFR 30 to 59), 27 had severe renal insufficiency (eGFR 15 to 29), and six had end-stage renal insufficiency (eGFR < 15). Median eGFR was 68 ml/min/1.73 m2 (interquartile range (IQR) 56 to 82), median whole blood Co was 3.3 µg/l (IQR 1.1 to 9.9), and median Cr was 2.0 µg/l (IQR 1.2 to 3.6). We did not observe an association between decreased eGFR and increased whole blood Co and Cr concentrations, but instead both increased Co and Cr were associated with higher eGFR, indicating better kidney function. Conclusion As patients with MoM hip arthroplasties get older, the prevalence of renal insufficiency among them will increase, and orthopaedic surgeons will increasingly have to evaluate whether or not this affects patient follow-up. The USA Food and Drug Administration suggests that closer follow-up may be needed for MoM patients with renal insufficiency. We did not observe accumulation of blood Co or Cr in MoM hip arthroplasty patients with mild to severe renal insufficiency. Cite this article: Bone Joint J 2021;103-B(7):1231–1237.

Download Full-text

Metal ion concentrations after metal-on-metal hip arthroplasty are not correlated with habitual physical activity levels

Hip International ◽

10.1177/1120700018814225 ◽

2018 ◽

Vol 29 (6) ◽

pp. 638-646 ◽

Cited By ~ 3

Author(s):

Jetse Jelsma ◽

Martijn GM Schotanus ◽

Rachel Senden ◽

Ide C Heyligers ◽

Bernd Grimm

Keyword(s):

Physical Activity ◽

At Risk ◽

Daily Living ◽

Metal Ion ◽

Hip Prosthesis ◽

Habitual Physical Activity ◽

Activity Levels ◽

Ion Concentrations ◽

Metal On Metal ◽

Physical Activity Levels

Introduction: Metal-on-metal (MoM) hip arthroplasties have shown high clinical failure rates with many patients at risk for a revision and under surveillance for high metal ion concentrations. Implant wear releasing such ions is assumed to be a function of use, i.e. the patient’s physical activity. This study aimed to assess whether habitual physical activity levels of MoM patients are correlated with metal ion concentrations and are higher in patients with high (at risk) than in patients with low (safe) metal ion concentrations. Methods: A cohort study was conducted of patients with any type of MoM hip prosthesis. Metal ion concentrations were determined using ICP-MS. Habitual physical activity of subjects was measured in daily living using an acceleration-based activity monitor. Outcome consisted of quantitative and qualitative activity parameters. Results: In total, 62 patients were included. Mean age at surgery was 60.8 ± 9.3 years and follow-up was 6.3 ± 1.4 years. Cobalt concentrations were highly elevated overall (112.4 ± 137.9 nmol/L) and significantly more in bilateral (184.8 ± 106.5 nmol/L) than in unilateral cases (87.8 ± 139.4 nmol/L). No correlations were found between physical activity parameters and metal ion concentrations. Subgroup analysis of patients with low versus high cobalt concentration showed no significant differences in habitual physical activity. Discussion: No correlation was found between physical activity levels and metal ion concentrations. Implant use by normal habitual activities of daily living seems not to influence metal ion concentrations.

Download Full-text