Systemic Effects of Metals Released from Arthroplasty Implants – a Brief Summary

Anastasia Rakow; Janosch Schoon

doi:10.1055/a-1187-1751

Zeitschrift für Orthopädie und Unfallchirurgie, Table of Contents

Z Orthop Unfall 2020; 158(05): 501-507
DOI: 10.1055/a-1187-1751

Review/Übersicht

Systemic Effects of Metals Released from Arthroplasty Implants – a Brief Summary

Article in several languages: English | deutsch

Authors

Anastasia Rakow

¹Center for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany

²Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
Janosch Schoon

³Klinik und Poliklinik für Orthopädie und Orthopädische Chirurgie, Universitätsmedizin Greifswald, Germany

⁴Julius Wolff Institute, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany

Abstract

In recent years, increasing concern has been raised regarding potential systemic toxicity of metals released from arthroplasty implants. A lack of valid metal thresholds for human (organ) toxicity and the prospect of multi-decade survival of modern hip and knee replacements pose special challenges. Indeed, evidence of systemic effects of metals released from such implants is largely missing. Systemic cobalt exposure has repeatedly been associated with cardiotoxic and neurotoxic effects, and also with thyroid dysfunction. The toxic potential of chromium is considered less pronounced. Yet, in arthroplasty there is usually a co-exposure to chromium and cobalt which complicates evaluation of element-specific effects. Toxicity of titanium dioxide nanoparticles has been subject to debate among international regulatory authorities. Their wide use in a variety of products in everyday life, such as toothpaste, cosmetics and food colorants, hampers the assessment of an arthroplasty-induced systemic titanium exposure. To date there is no clear evidence for systemic complications due to titanium dioxide released from arthroplasty implants. Release of further metals such as tantalum, niobium, nickel, vanadium and zirconium from hip and knee replacement implants has been described occasionally, but systemic effects of respective long-term exposure scenarios are unknown. Generally, the characterization of all released metals regarding their chemical and physical specifications is critical for the evaluation of potential systemic risks. Systematic studies investigating the accumulation of metals relevant in arthroplasty in different organs/organ systems and the biological consequences of such accumulations are urgently needed.

Key words

metal ions - wear - corrosion - metal toxicity - systemic effects

Full Text

References

References/Literatur
1 Bradberry SM, Wilkinson JM, Ferner RE. Systemic toxicity related to metal hip prostheses. Clin Toxicol (Phila) 2014; 52: 837-847 doi:10.3109/15563650.2014.944977
2 Sotos JG, Tower SS. Systemic disease after hip replacement: aeromedical implications of arthroprosthetic cobaltism. Aviat Space Environ Med 2013; 84: 242-245 doi:10.3357/asem.3262.2013
3 McMaster WC, Patel J. Adverse local tissue response lesion of the knee associated with Morse taper corrosion. J Arthroplasty 2013; 28: 375.e5-e8 doi:10.1016/j.arth.2012.04.005
4 Rakow A, Schoon J, Dienelt A. et al. Influence of particulate and dissociated metal-on-metal hip endoprosthesis wear on mesenchymal stromal cells in vivo and in vitro. Biomaterials 2016; 98: 31-40 doi:10.1016/j.biomaterials.2016.04.023
5 Umar M, Jahangir N, Faisal Khan M. et al. Cobalt cardiomyopathy in hip arthroplasty. Arthroplast Today 2019; 5: 371-375 doi:10.1016/j.artd.2019.04.010
6 Steens W, von Foerster G, Katzer A. Severe cobalt poisoning with loss of sight after ceramic-metal pairing in a hip–a case report. Acta Orthop 2006; 77: 830-832 doi:10.1080/17453670610013079
7 Tower SS. Arthroprosthetic cobaltism: neurological and cardiac manifestations in two patients with metal-on-metal arthroplasty: a case report. J Bone Joint Surg Am 2010; 92: 2847-2851 doi:10.2106/JBJS.J.00125
8 Rizzetti MC, Liberini P, Zarattini G. et al. Loss of sight and sound. Could it be the hip?. Lancet 2009; 373: 1052 doi:10.1016/S0140-6736(09)60490-6
9 Devlin JJ, Pomerleau AC, Brent J. et al. Clinical features, testing, and management of patients with suspected prosthetic hip-associated cobalt toxicity: a systematic review of cases. J Med Toxicol 2013; 9: 405-415 doi:10.1007/s13181-013-0320-0
10 Ort MJ, Geissler S, Rakow A. et al. The allergic bone marrow? The immuno-capacity of the human bone marrow in context of metal-associated hypersensitivity reactions. Front Immunol 2019; 10: 2232 doi:10.3389/fimmu.2019.02232
11 Ebert B, Jelkmann W. Intolerability of cobalt salt as erythropoietic agent. Drug Test Anal 2014; 6: 185-189 doi:10.1002/dta.1528
12 Laitinen M, Nieminen J, Reito A. et al. High blood metal ion levels in 19 of 22 patients with metal-on-metal hinge knee replacements. Acta Orthop 2017; 88: 269-274 doi:10.1080/17453674.2017.1283846
13 Fillingham YA, Della Valle CJ, Bohl DD. et al. Serum Metal Levels for Diagnosis of Adverse Local Tissue Reactions Secondary to Corrosion in Metal-on-Polyethylene Total Hip Arthroplasty. J Arthroplasty 2017; 32 (9 Suppl.): S272-S277 doi:10.1016/j.arth.2017.04.016
14 Matsen Ko LJ, Pollag KE, Yoo JY. et al. Serum metal ion levels following total hip arthroplasty with modular dual mobility components. J Arthroplasty 2016; 31: 186-189 doi:10.1016/j.arth.2015.07.035
15 Fox KA, Phillips TM, Yanta JH. et al. Fatal cobalt toxicity after total hip arthroplasty revision for fractured ceramic components. Clin Toxicol (Phila) 2016; 54: 874-877 doi:10.1080/15563650.2016.1214274
16 Catalani S, Rizzetti MC, Padovani A. et al. Neurotoxicity of cobalt. Hum Exp Toxicol 2012; 31: 421-437 doi:10.1177/0960327111414280
17 Gessner BD, Steck T, Woelber E. et al. A systematic review of systemic cobaltism after wear or corrosion of chrome-cobalt hip implants. J Patient Saf 2019; 15: 97-104 doi:10.1097/PTS.0000000000000220
18 Berber R, Abdel-Gadir A, Rosmini S. et al. Assessing for cardiotoxicity from metal-on-metal hip implants with advanced multimodality imaging techniques. J Bone Joint Surg Am 2017; 99: 1827-1835 doi:10.2106/JBJS.16.00743
19 Fung ES, Monnot A, Kovochich M. et al. Characteristics of cobalt-related cardiomyopathy in metal hip implant patients: an evaluation of 15 published reports. Cardiovasc Toxicol 2018; 18: 206-220 doi:10.1007/s12012-017-9433-z
20 Wyles CC, Wright TC, Bois MC. et al. Myocardial cobalt levels are elevated in the setting of total hip arthroplasty. J Bone Joint Surg Am 2017; 99: e118 doi:10.2106/JBJS.17.00159
21 Choi HI, Hong JA, Kim MS. et al. Severe cardiomyopathy due to arthroprosthetic cobaltism: report of two cases with different outcomes. Cardiovasc Toxicol 2019; 19: 82-89 doi:10.1007/s12012-018-9480-0
22 Machado C, Appelbe A, Wood R. Arthroprosthetic cobaltism and cardiomyopathy. Heart Lung Circ 2012; 21: 759-760 doi:10.1016/j.hlc.2012.03.013
23 Paustenbach DJ, Tvermoes BE, Unice KM. et al. A review of the health hazards posed by cobalt. Crit Rev Toxicol 2013; 43: 316-362 doi:10.3109/10408444.2013.779633
24 Unice KM, Kerger BD, Paustenbach DJ. et al. Refined biokinetic model for humans exposed to cobalt dietary supplements and other sources of systemic cobalt exposure. Chem Biol Interact 2014; 216: 53-74 doi:10.1016/j.cbi.2014.04.001
25 Clark MJ, Prentice JR, Hoggard N. et al. Brain structure and function in patients after metal-on-metal hip resurfacing. AJNR Am J Neuroradiol 2014; 35: 1753-1758 doi:10.3174/ajnr.A3922
26 Lodge F, Khatun R, Lord R. et al. Prevalence of subclinical cardiac abnormalities in patients with metal-on-metal hip replacements. Int J Cardiol 2018; 271: 274-280 doi:10.1016/j.ijcard.2018.05.047
27 Apostoli P, Catalani S, Zaghini A. et al. High doses of cobalt induce optic and auditory neuropathy. Exp Toxicol Pathol 2013; 65: 719-727 doi:10.1016/j.etp.2012.09.006
28 Deutsche Gesellschaft für Endoprothetik e.V. (AE). Stellungnahme der AE zur Metallkorrosion (09.06.2016). Online (last access: 13.05.2020): https://www.ae-germany.com/images/ae/oeffentlich/pdf-handlungsanweisungen/01_Metallkorrosion.pdf
29 The European Federation of National Associations of Orthopaedics and Traumatology (EFORT). Consensus statement „Current Evidence on the Management of Metal-on-Metal Bearings“ (16.04.1012). Online (last access: 13.05.2020): https://www.efort.org/wp-content/uploads/2013/10/2012_05_10_MoM_Consensus_statement1.pdf
30 Morrell AP, Floyd H, Mosselmans JFW. et al. Improving our understanding of metal implant failures: Multiscale chemical imaging of exogenous metals in ex-vivo biological tissues. Acta Biomater 2019; 98: 284-293 doi:10.1016/j.actbio.2019.05.071
31 Xia Z, Ricciardi BF, Liu Z. et al. Nano-analyses of wear particles from metal-on-metal and non-metal-on-metal dual modular neck hip arthroplasty. Nanomedicine 2017; 13: 1205-1217 doi:10.1016/j.nano.2016.11.003
32 Katz SA, Salem H. The toxicology of chromium with respect to its chemical speciation: a review. J Appl Toxicol 1993; 13: 217-224 doi:10.1002/jat.2550130314
33 De Smet K, De Haan R, Calistri A. et al. Metal ion measurement as a diagnostic tool to identify problems with metal-on-metal hip resurfacing. J Bone Joint Surg Am 2008; 90 (Suppl. 04) S202-S208 doi:10.2106/JBJS.H.00672
34 Schoon J, Geissler S, Traeger J. et al. Multi-elemental nanoparticle exposure after tantalum component failure in hip arthroplasty: in-depth analysis of a single case. Nanomedicine 2017; 13: 2415-2423 doi:10.1016/j.nano.2017.08.004
35 Hothi HS, Berber R, Whittaker RK. et al. The relationship between cobalt/chromium ratios and the high prevalence of head-stem junction corrosion in metal-on-metal total hip arthroplasty. J Arthroplasty 2016; 31: 1123-1127 doi:10.1016/j.arth.2015.11.014
36 Pazzaglia UE, Apostoli P, Congiu T. et al. Cobalt, chromium and molybdenum ions kinetics in the human body: data gained from a total hip replacement with massive third body wear of the head and neuropathy by cobalt intoxication. Arch Orthop Trauma Surg 2011; 131: 1299-1308 doi:10.1007/s00402-011-1268-7
37 Durrani SK, Noble PC, Sampson B. et al. Changes in blood ion levels after removal of metal-on-metal hip replacements: 16 patients followed for 0–12 months. Acta Orthop 2014; 85: 259-265 doi:10.3109/17453674.2014.913223
38 Newton AW, Ranganath L, Armstrong C. et al. Differential distribution of cobalt, chromium, and nickel between whole blood, plasma and urine in patients after metal-on-metal (MoM) hip arthroplasty. J Orthop Res 2012; 30: 1640-1646 doi:10.1002/jor.22107
39 Daniel J, Ziaee H, Pradhan C. et al. Renal clearance of cobalt in relation to the use of metal-on-metal bearings in hip arthroplasty. J Bone Joint Surg Am 2010; 92: 840-845 doi:10.2106/JBJS.H.01821
40 von Burg R, Liu D. Chromium and hexavalent chromium. J Appl Toxicol 1993; 13: 225-230 doi:10.1002/jat.2550130315
41 Skocaj M, Filipic M, Petkovic J. et al. Titanium dioxide in our everyday life; is it safe?. Radiol Oncol 2011; 45: 227-247 doi:10.2478/v10019-011-0037-0
42 Grupp TM, Weik T, Bloemer W. et al. Modular titanium alloy neck adapter failures in hip replacement–failure mode analysis and influence of implant material. BMC Musculoskelet Disord 2010; 11: 3 doi:10.1186/1471-2474-11-3
43 Yao JJ, Lewallen EA, Trousdale WH. et al. Local cellular responses to titanium dioxide from orthopedic implants. Biores Open Access 2017; 6: 94-103 doi:10.1089/biores.2017.0017
44 Swiatkowska I, Martin N, Hart AJ. Blood titanium level as a biomarker of orthopaedic implant wear. J Trace Elem Med Biol 2019; 53: 120-128 doi:10.1016/j.jtemb.2019.02.013
45 Swiatkowska I, Martin NG, Henckel J. et al. Blood and plasma titanium levels associated with well-functioning hip implants. J Trace Elem Med Biol 2020; 57: 9-17 doi:10.1016/j.jtemb.2019.09.005
46 Koller D, Bramhall P, Devoy J. et al. Analysis of soluble or titanium dioxide derived titanium levels in human whole blood: consensus from an inter-laboratory comparison. Analyst 2018; 143: 5520-5529 doi:10.1039/c8an00824h
47 Levine BR, Hsu AR, Skipor AK. et al. Ten-year outcome of serum metal ion levels after primary total hip arthroplasty: a concise follow-up of a previous report*. J Bone Joint Surg Am 2013; 95: 512-518 doi:10.2106/JBJS.L.00471
48 Gofton W, Beaule PE. Serum metal ions with a titanium modular neck total hip replacement system. J Arthroplasty 2015; 30: 1781-1786 doi:10.1016/j.arth.2015.04.040
49 Song B, Liu J, Feng X. et al. A review on potential neurotoxicity of titanium dioxide nanoparticles. Nanoscale Res Lett 2015; 10: 1042 doi:10.1186/s11671-015-1042-9
50 Ataya A, Kline KP, Cope J. et al. Titanium exposure and yellow nail syndrome. Respir Med Case Rep 2015; 16: 146-147 doi:10.1016/j.rmcr.2015.10.002
51 Berglund F, Carlmark B. Titanium, sinusitis, and the yellow nail syndrome. Biol Trace Elem Res 2011; 143: 1-7 doi:10.1007/s12011-010-8828-5
52 Itagaki H, Katuhiko S. Yellow nail syndrome following multiple orthopedic surgeries: a case report. J Med Case Rep 2019; 13: 200 doi:10.1186/s13256-019-2136-2
53 Sjögren B, Iregren A, Montelius J, Yokel RA. Aluminum. In: Fowler BA, Nordberg M. eds. Handbook on the Toxicology of Metals. 4th ed.. San Diego: Academic Press;; 2015: 549-564
54 Yokel RA. The toxicology of aluminum in the brain: a review. Neurotoxicology 2000; 21: 813-828
55 Catalani S, Stea S, Beraudi A. et al. Vanadium release in whole blood, serum and urine of patients implanted with a titanium alloy hip prosthesis. Clin Toxicol (Phila) 2013; 51: 550-556 doi:10.3109/15563650.2013.818682
56 Dunstan E, Sanghrajka AP, Tilley S. et al. Metal ion levels after metal-on-metal proximal femoral replacements: a 30-year follow-up. J Bone Joint Surg Br 2005; 87: 628-631 doi:10.1302/0301-620X.87B5.15384
57 Assem FL, Oskarsson A. Vanadium. In: Fowler BA, Nordberg M. eds. Handbook on the Toxicology of Metals. 4th ed.. San Diego:: Academic Press;; 2015: 1347-1367
58 Schoon J, Ort MJ, Huesker K. et al. Diagnosis of metal hypersensitivity in total knee arthroplasty: a case report. Front Immunol 2019; 10: 2758 doi:10.3389/fimmu.2019.02758
59 Phedy P, Djaja YP, Boedijono DR. et al. Hypersensitivity to orthopaedic implant manifested as erythroderma: timing of implant removal. Int J Surg Case Rep 2018; 49: 110-114 doi:10.1016/j.ijscr.2018.06.011
60 Akil S, Newman JM, Shah NV. et al. Metal hypersensitivity in total hip and knee arthroplasty: current concepts. J Clin Orthop Trauma 2018; 9: 3-6 doi:10.1016/j.jcot.2017.10.003
61 Krenn V, Perino G. Histological Diagnosis of implant-associated Pathologies. Berlin, Heidelberg: Springer; 2017
62 Teo WZW, Schalock PC. Metal hypersensitivity reactions to orthopedic implants. Dermatol Ther (Heidelb) 2017; 7: 53-64 doi:10.1007/s13555-016-0162-1
63 Hallab NJ, Anderson S, Caicedo M. et al. Immune responses correlate with serum-metal in metal-on-metal hip arthroplasty. J Arthroplasty 2004; 19: 88-93 doi:10.1016/j.arth.2004.09.012
64 Savarino L, Granchi D, Ciapetti G. et al. Effects of metal ions on white blood cells of patients with failed total joint arthroplasties. J Biomed Mater Res 1999; 47: 543-550 doi:10.1002/(sici)1097-4636(19991215)47:4<543::aid-jbm11>3.0.co;2-g
65 Catelas I, Lehoux EA, Hurda I. et al. Do patients with a failed metal-on-metal hip implant with a pseudotumor present differences in their peripheral blood lymphocyte subpopulations?. Clin Orthop Relat Res 2015; 473: 3903-3914 doi:10.1007/s11999-015-4466-8
66 European Chemicals Agency (ECHA). Opinion proposing harmonised classification and labelling at EU level of cobalt (22.09.2017). Im Internet (Stand: 12.05.2020): https://echa.europa.eu/documents/10162/b7316b11-ae65-1dd0-2e64-bb6ad3efbd82
67 Novak CC, Hsu AR, Della Valle CJ. et al. Metal ion levels in maternal and placental blood after metal-on-metal total hip arthroplasty. Am J Orthop (Belle Mead NJ) 2014; 43: E304-E308
68 Ziaee H, Daniel J, Datta AK. et al. Transplacental transfer of cobalt and chromium in patients with metal-on-metal hip arthroplasty: a controlled study. J Bone Joint Surg Br 2007; 89: 301-305 doi:10.1302/0301-620X.89B3.18520
69 deSouza RM, Wallace D, Costa ML. et al. Transplacental passage of metal ions in women with hip resurfacing: no teratogenic effects observed. Hip Int 2012; 22: 96-99 doi:10.5301/HIP.2012.9100
70 Reiner T, Sorbi R, Müller M. et al. Blood metal ion release after primary total knee arthroplasty: a prospective study. Orthop Surg 2020; 12: 396-403 doi:10.1111/os.12591
71 Lardanchet JF, Taviaux J, Arnalsteen D. et al. One-year prospective comparative study of three large-diameter metal-on-metal total hip prostheses: serum metal ion levels and clinical outcomes. Orthop Traumatol Surg Res 2012; 98: 265-274 doi:10.1016/j.otsr.2011.11.009
72 Lons A, Putman S, Pasquier G. et al. Metallic ion release after knee prosthesis implantation: a prospective study. Int Orthop