Advertisement

International Orthopaedics

, Volume 43, Issue 1, pp 85–96 | Cite as

Pleomorphic clinical spectrum of metallosis in total hip arthroplasty

  • Francesco PisanuEmail author
  • Carlo Doria
  • Matteo Andreozzi
  • Marco Bartoli
  • Laura Saderi
  • Giovanni Sotgiu
  • Paolo Tranquilli Leali
Original Paper
  • 90 Downloads

Abstract

Purpose

To summarize the biological effects of metal debris from hip arthroplasties which characterize a polymorphic clinical spectrum of local and remote manifestation.

Methods

Retrospective study. Patient, implant, and surgical characteristics were collected, including implant survival, clinical manifestations, cause of arthroplasty revision or implant failure, and peri- and intra-operative complications. The primary endpoint was implant survivorship. Hip revision arthroplasty was decided considering clinical signs and symptoms, abnormal imaging (XR, MR, TC, echotomography, scintigraphy), and blood metal ion level. An ad hoc electronic form was used to collect demographic, epidemiological, and clinical variables. In-between group comparisons of quantitative variables were performed with the Student t test and the Mann-Whitney for parametric and non-parametric variables, respectively. Logistic regression analyses were carried out to assess the relationship between clinical and radiographic characteristics and stem and cup revision. Radiographic measurements of implant positioning validity and reliability were assessed using Krippendorff’s alpha reliability coefficient. The statistical software STATA version 15 (StatsCorp, TX) was used to perform statistical computations.

Results

In this MoM THA series, the most incident cause of implant failure was ARMD in 11 out of 14 (78.6%) patients. All clinical failure manifestations, revision surgery highlights, and intra-operative findings are reported.

Conclusions

The local adverse reactions include lesions of different clinical relevance from small asymptomatic soft tissue lesions to dramatic osteolysis, necrosis, effusion, and growing masses which can cause secondary pathological effects. Symptoms of systemic toxicity are rarely described but may have been largely unreported in literature. Despite the extensive literature on the topic, the patient’s management is still uncertain and challenging. Every metallic implant (e.g., screws, plates, spinal instrumentations) has a potential local or systemic adverse effect. Organizing a national registry of arthroplasty should be mandatory, in order to collect data about the patients, the surgery, the implanted device (with a careful post-marketing tracking), and the follow-up for all the procedures performed at a national level. The data collected in the registry will allow to analyze the implant survival and to better recognize the undesirable and sometimes unexpected effects of different biomaterials on the whole body.

Keywords

Biomaterials Metal ions Metallosis Pseudotumours ARMD ALVAL Total hip arthroplasty 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    MacDonald SJ, McCalden RW, Chess DG, Bourne RB, Rorabeck CH, Cleland D, Leung F (2003) Metal-on-metal versus polyethylene in hip arthroplasty: a randomized clinical trial. Clin Orthop Relat Res 406:282–296CrossRefGoogle Scholar
  2. 2.
    Corten K, MacDonald SJ (2010) Hip resurfacing data from national joint registries: what do they tell us? What do they not tell us? Clin Orthop Relat Res 468(2):351–357CrossRefGoogle Scholar
  3. 3.
    Smith AJ, Dieppe P, Vernon K, Porter M, Blom AW (2012) Failure rates of stemmed metal on metal hip replacements: analysis of data from the National Joint Registry of England and Wales. Lancet 379(9822):1199–1204CrossRefGoogle Scholar
  4. 4.
    Bordini B, Stea S, Castagnini F, Busanelli L, Giardina F, Toni A (2018) The influence of bearing surfaces on periprosthetic hip infections: analysis of thirty nine thousand, two hundred and six cementless total hip arthroplasties. Int Orthop.  https://doi.org/10.1007/s00264-018-4097-2
  5. 5.
    Hothi HS, Berber R, Panagiotopoulos AC, Whittaker RK, Rhead C, Skinner JA, Hart AJ (2016) Clinical significance of corrosion of cemented femoral stems in metal-on-metal hips: a retrieval study. Int Orthop 40:2247–2254CrossRefGoogle Scholar
  6. 6.
    Azam MQ, McMahon S, Hawdon G, Sankineani SR (2016) Survivorship and clinical outcome of Birmingham hip resurfacing: a minimum ten years’ follow-up. Int Orthop 40:1–7CrossRefGoogle Scholar
  7. 7.
    American Academy of Orthopaedic Surgeons (2012) Information statement, Current concerns with metal-on-metal hip arthroplasty. Available at: www.aaos.org/about/papers/advistmt/1035
  8. 8.
    Matharu GS, Mellon SJ, Murray DW, Pandit HG (2015) Follow-up guidance for metal-on-metal hip replacement patients should be updated. Int Orthop 39:609–610CrossRefGoogle Scholar
  9. 9.
    Guenther D, Thomas P, Kendoff D, Omar M, Gehrke T, Haasper C (2016) Allergic reactions in arthroplasty: myth or serious problem? Int Orthop 40:239–244CrossRefGoogle Scholar
  10. 10.
    Kretzer JP, Mueller U, Streit MR, Kiefer H, Sonntag R, Streicher RM, Reinders J (2018) Ion release in ceramic bearings for total hip replacement: results from an in vitro and an in vivo study. Int Orthop 42:65–70CrossRefGoogle Scholar
  11. 11.
    Benelli G, Maritato M, Cerulli Mariani P, Sasso F (2018) Revision of ASR hip arthroplasty: analysis of two hundred and ninety six recalled patients at seven years. Int Orthop.  https://doi.org/10.1007/s00264-018-4128-z
  12. 12.
    Bisschop R, Boomsma MF, Van Raay JJAM, Tiebosch ATMG, Maas M, Gerritsma CLE (2013) High prevalence of pseudotumors in patients with a Birmingham Hip Resurfacing prosthesis: a prospective cohort study of one hundred and twenty nine patients. J Bone Joint Surg Am 95(17):1554–1560CrossRefGoogle Scholar
  13. 13.
    Khatkar H, Hothi H, de Villiers D, Lausmann C, Kendoff D, Gehrke T, Skinner J, Hart A (2017) Retrieval analysis of ceramic-coated metal-on-polyethylene total hip replacements. Int Orthop 41:1101–1105CrossRefGoogle Scholar
  14. 14.
    Scully WF, Teeny SM (2013) Pseudotumor associated with metal-on-polyethylene total hip arthroplasty. Orthopedics 36(5):e666–e670CrossRefGoogle Scholar
  15. 15.
    Bisseling P, Tan T, Lu Z, Campbell PA, Susante JL (2013) Absence of a metal on metal bearing does not preclude the formation of a destructive pseudotumor in the hip – a case report. Acta Orthop 84:437–441CrossRefGoogle Scholar
  16. 16.
    Mao X, Tay GH, Godbolt DB, Crawford RW (2012) Pseudotumor in a well fixed metal on polyethylene uncemented hip arthroplasty. J Arthroplast 27(3):493.e13–493.e17.  https://doi.org/10.1016/j.arth.2011.07.015 CrossRefGoogle Scholar
  17. 17.
    Hsu AR, Gross CE, Levine BR (2012) Pseudotumor from modular neck corrosion after ceramic on polyethylene total hip arthroplasty. Am J Orthop 41(9):422–426Google Scholar
  18. 18.
    Castagnini F, Bordini B, Stea S, Calderoni PP, Masetti C, Busanelli L (2018) Highly porous titanium cup in cementless total hip arthroplasty: registry results at eight years. Int Orthop.  https://doi.org/10.1007/s00264-018-4102-9
  19. 19.
    Apostoli P, Catalani S, Zaghini A, Mariotti A, Poliani PL, Vielmi V, Semeraro F, Duse S, Porzionato A, Macchie V, Padovani A, Rizzetti MC, De Caro D (2013) High doses of cobalt induce optic and auditory neuropathy. Exp Toxicol Pathol 65:719–727CrossRefGoogle Scholar
  20. 20.
    Paustenbach DJ, Galbraith DA, Finley BL (2014) Interpreting cobalt blood concentrations in hip implant patients. Clin Toxicol (Phila) 52(2):98–112CrossRefGoogle Scholar
  21. 21.
    Bradberry SM, Wilkinson JM, Ferner RE (2014) Systemic toxicity related to metal hip prostheses. Clin Toxicol 52(8):837–847.  https://doi.org/10.3109/15563650.2014.944977 CrossRefGoogle Scholar
  22. 22.
    Gessner BD, Steck T, Woelber E, Tower SS (2015) A systematic review of systemic cobaltism after wear or corrosion of chrome-cobalt hip implants. J Patient Saf.  https://doi.org/10.1097/PTS.0000000000000220
  23. 23.
    Matthies AK, Henckel J, Cro S, Suarez A, Noble PC, Skinner J, Hart AJ (2014) Predicting wear and blood metal ion levels in metal-on-metal hip resurfacing. J Orthop Res 32(1):167–174CrossRefGoogle Scholar
  24. 24.
    Bouveau V, Haen TX, Poupon J, Nich C (2018) Outcomes after revision of metal on metal hip resurfacing to total arthroplasty using the direct anterior approach. Int Orthop.  https://doi.org/10.1007/s00264-018-3858-2
  25. 25.
    Tao R, Liu F, Liu Y, Lu Y, Xu H, Cao Y, Zhou Z, Wang W (2018) A prospective comparative study of hip resurfacing arthroplasty and large-diameter head metal-on-metal total hip arthroplasty in younger patients-a minimum of five year follow-up. Int Orthop.  https://doi.org/10.1007/s00264-018-3819-9
  26. 26.
    Fessy MH, N’diaye A, Carret JP, Fischer LP (1999) Locating the center of rotation of the hip. Surg Radiol Anat 21:247–250CrossRefGoogle Scholar
  27. 27.
    Bolland BJRF, Culliford DJ, Langton DJ, Millington JPS, Arden NK, Latham JM (2011) High failure rates with a large diameter hybrid metal-on-metal total hip replacement: clinical radiological and retrieval analysis. J Bone Joint Surg Br 93(5):608–615CrossRefGoogle Scholar
  28. 28.
    Hartmann A, Hannemann F, Lutzner J, Seidler A, Drexler H, Günther KP, Schmitt J (2013) Metal ion concentrations in body fluids after implantation of hip replacements with metal-on-metal bearing – systematic review of clinical and epidemiological studies. PLoS One 8(8):e70359CrossRefGoogle Scholar
  29. 29.
    Liow MHL, Kwon YM (2017) Metal-on-metal total hip arthroplasty: risk factors for pseudotumours and clinical systematic evaluation. Int Orthop 41(5):885–892CrossRefGoogle Scholar
  30. 30.
    Kwon YM, Ostlere SJ, McLardy-Smith P, Athanasou NA, Gill HS, Murray DW (2011) “Asymptomatic” pseudotumors after metal-on-metal hip resurfacing arthroplasty: prevalence and metal ion study. J Arthroplast 26(4):511–518CrossRefGoogle Scholar
  31. 31.
    Williams DH, Greidanus NV, Masri BA, Duncan CP, Garbuz DS (2011) Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am 93(23):2164–2171CrossRefGoogle Scholar
  32. 32.
    Hart AJ, Satchithananda K, Liddle AD, Sabah SA, McRobbie D, Henckel J, Cobb JP, Skinner JA, Mitchell AW (2012) Pseudo-tumors in association with well-functioning metal-on-metal hip prostheses: a case-control study using three-dimensional computed tomography and magnetic resonance imaging. J Bone Joint Surg Am 94(4):317–325CrossRefGoogle Scholar
  33. 33.
    Sabah SA, Mitchell AW, Henckel J, Sandison A, Skinner A, Hart AJ (2011) Magnetic resonance imaging findings in painful metal-on- metal hips: a prospective study. J Arthroplast 26(1):71–6.e2CrossRefGoogle Scholar
  34. 34.
    Campe CB, Palmer WE (2013) MR imaging of metal-on-metal hip prostheses. Magn Reson Imaging Clin N Am 21:155–168CrossRefGoogle Scholar
  35. 35.
    Algarni AD, Huk OL, Pelmus M (2012) Metallosis-induced iliopsoas bursal cyst causing venous obstruction and lower-limb swelling after metal-on-metal THA. Orthopedics 35(12):e1811–e1814CrossRefGoogle Scholar
  36. 36.
    Doria C, De Santis V, Falcone G, Proietti L, De Santis E (2003) Osseointegration in hip prostheses: experimental study in sheep. Int Orthop 27:272–277CrossRefGoogle Scholar
  37. 37.
    Gruber FW, Böck A, Trattnig S, Lintner F, Ritschl P (2007) Cystic lesion of the groin due to metallosis: a rare long-term complication of metal-on-metal total hip arthroplasty. J Arthroplast 22(6):923–927CrossRefGoogle Scholar
  38. 38.
    Caicedo MS, Pennekamp PH, McAllister K, Jacobs JJ, Hallab NJ (2010) Soluble ions more than particulate cobalt-alloy implant debris induce monocyte costimulatory molecule expression and release of proinflammatory cytokines critical to metal-induced lymphocyte reactivity. J Biomed Mater Res A 93(4):1312–1321Google Scholar
  39. 39.
    Tuan RS, Lee FY, Konttinen Y, Wilkinson JM, Smith RL (2008) What are the local and systemic biological reactions and mediators to wear debris and what host factors determine or modulate the biological response to wear particles? J Am Acad Orthop Surg 16(Suppl 1):S42–S48CrossRefGoogle Scholar
  40. 40.
    Hallab NJ, Mikecz K, Vermes C, Skipor A, Jacobs JJ (2001) Orthopaedic implant related metal toxicity in terms of human lymphocyte reactivity to metal-protein complexes produced from cobalt-base and titanium-base implant alloy degradation. Mol Cell Biochem 222:127–136CrossRefGoogle Scholar
  41. 41.
    Tkaczyk C, Huk OL, Mwale F, Antoniou J, Zukor DJ, Petit A, Tabrizian M (2010) Investigation of the binding of Cr(III) complexes to bovine and human serum proteins: a proteomic approach. J Biomed Mater Res 94A(1):214–222.  https://doi.org/10.1002/jbm.a.32700 CrossRefGoogle Scholar
  42. 42.
    Hart AJ, Matthies A, Henckel J, Ilo K, Skinner J, Noble P (2012) Understanding why metal-on-metal hip arthroplasties fail: a comparison between patients with well-functioning and revised Birmingham hip resurfacing arthroplasties. AAOS exhibit selection. J Bone Joint Surg Am 94(4):e22CrossRefGoogle Scholar
  43. 43.
    Donell ST, Darrah C, Nolan JF, Wimhurst J, Toms A, Barker THW, Case CP, Tucker JK (2010) Early failure of the Ultima metal-on-metal total hip replacement in the presence of normal plain radiographs. J Bone Joint Surg Br 92(11):1501–1508CrossRefGoogle Scholar
  44. 44.
    Siddiqui IA, Sabah SA, Satchithananda K, Lim AK, Cro S, Henckel J, Skinner JA, Hart AJ (2014) A comparison of the diagnostic accuracy of MARS MRI and ultrasound of the painful metal-on-metal hip arthroplasty. Acta Orthop 85(4):375–382CrossRefGoogle Scholar
  45. 45.
    Robinson E, Henckel J, Sabah S, Satchithananda K, Skinner J, Hart A (2014) Cross-sectional imaging of metal-on-metal hip arthroplasties. Can we substitute MARS MRI with CT? Acta Orthop 85(6):577–584CrossRefGoogle Scholar
  46. 46.
    Hannemann F et al (2013) European multidisciplinary consensus statement on the use and monitoring of metal-on-metal bearings for total hip replacement and hip resurfacing. Orthop Traumatol Surg Res 99:263–271CrossRefGoogle Scholar
  47. 47.
    MHRA. Medical device alert. All metal-on-metal (MoM) hip replacements: updated advice for follow-up of patients. MDA/2017/018.29 June 2017. Available at: http://assets.publishing.service.gov.uk/media/5954ca1ded915d0baa00009b/MDA-2017-018
  48. 48.
    Hart AJ, Sabah SA, Bandi AS, Maggiore P, Tarassoli P, Sampson B, Skinner JA (2011) Sensitivity and specificity of blood cobalt and chromium metal ions for predicting failure of metal-on-metal hip replacement. J Bone Joint Surg Br 93(10):1308–1313CrossRefGoogle Scholar
  49. 49.
    Manunta ML, Careddu GM, Masala G, Columbano N, Doria C, Crissantu L, Sanna Passino E (2008) Lumbar interbody expanding cage. A preliminary study on an animal model. Vet Comp Orthop Traumatol 4:382–384Google Scholar
  50. 50.
    Floerkemeier T, Budde S, Wirries N, von Lewinski G, Windhagen H, Ezechieli M (2017) The outcome of the partial resurfacing arthroplasty of the hip shows high numbers of failures and conversion to total arthroplasty. Int Orthop 41(10):2001–2008CrossRefGoogle Scholar
  51. 51.
    Berber R, Skinner JA, Hart AJ (2016) Management of metal-on-metal hip implant patients: who, when and how to revise? World J Orthop 7(5):272–279CrossRefGoogle Scholar

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  1. 1.Università degli Studi di SassariSassariItaly

Personalised recommendations