Introduction. We aimed to identify genes associated with the development of
Introduction: There are ongoing concerns regarding metal wear debris following the use of metal-on-metal (MonM) bearings for hip surface and total arthroplasty. A Type IV Hypersensitivity reaction to MonM articulations has previously been identified (aseptic lymphocyte dominated vasculitis associated lesion, ALVAL) but little is known of its incidence, diagnosis or management. Persisting groin pain in MonM patients may be undiagnosed
Aims. Metal particles detached from metal-on-metal hip prostheses (MoM-THA) have been shown to cause inflammation and destruction of tissues. To further explore this, we investigated the histopathology (aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) score) and metal concentrations of the periprosthetic tissues obtained from patients who underwent revision knee arthroplasty. We also aimed to investigate whether accumulated metal debris was associated with ALVAL-type reactions in the synovium. Methods. Periprosthetic metal concentrations in the synovia and histopathological samples were analyzed from 230 patients from our institution from October 2016 to December 2019. An ordinal regression model was calculated to investigate the effect of the accumulated metals on the histopathological reaction of the synovia. Results. Median metal concentrations were as follows: cobalt: 0.69 μg/g (interquartile range (IQR) 0.10 to 6.10); chromium: 1.1 μg/g (IQR 0.27 to 4.10); and titanium: 1.6 μg/g (IQR 0.90 to 4.07). Moderate
Aims. Hip resurfacing remains a potentially valuable surgical procedure for appropriately-selected patients with optimised implant choices. However, concern regarding high early failure rates continues to undermine confidence in use. A large contributor to failure is adverse local tissue reactions around metal-on-metal (MoM) bearing surfaces. Such phenomena have been well-explored around MoM total hip arthroplasties, but comparable data in equivalent hip resurfacing procedures is lacking. In order to define genetic predisposition, we performed a case-control study investigating the role of human leucocyte antigen (HLA) genotype in the development of pseudotumours around MoM hip resurfacings. Methods. A matched case-control study was performed using the prospectively-collected database at the host institution. In all, 16 MoM hip resurfacing 'cases' were identified as having symptomatic periprosthetic pseudotumours on preoperative metal artefact reduction sequence (MARS) MRI, and were subsequently histologically confirmed as high-grade aseptic lymphocyte-dominated vasculitis-associated lesions (ALVALs) at revision surgery. ‘Controls’ were matched by implant type in the absence of evidence of pseudotumour. Blood samples from all cases and controls were collected prospectively for high resolution genetic a nalysis targeting 11 separate HLA loci. Statistical significance was set at 0.10 a priori to determine the association between HLA genotype and pseudotumour formation, given the small sample size. Results. Using a previously-reported
This study compared the cobalt and chromium serum ion concentration of patients treated with two different metal-on-metal (MoM) hinged total knee arthroplasty (TKA) systems, as well as a titanium nitride (TiN)-coated variant. A total of 63 patients (65 implants) were treated using either a MoM-coated (n = 29) or TiN-coated (n = 7) hinged TKA (GenuX mobile bearing, MUTARS; Implantcast, Germany) versus the BPKS (Brehm, Germany) hinged TKA (n = 27), in which the weight placed on the MoM hinge is diffused through a polyethylene (PE) inlay, reducing the direct load on the MoM hinge. Serum cobalt and chromium ion concentrations were assessed after minimum follow-up of 12 months, as well as functional outcome and quality of life.Aims
Methods
We present a series of 35 patients (19 men and
16 women) with a mean age of 64 years (36.7 to 75.9), who underwent
total hip replacement using the ESKA dual-modular short stem with
metal on-polyethylene bearing surfaces. This implant has a modular
neck section in addition to the modular head. Of these patients,
three presented with increasing post-operative pain due to pseudotumour
formation that resulted from corrosion at the modular neck-stem
junction. These patients underwent further surgery and aseptic lymphocytic
vaculitis associated lesions were demonstrated on histological analysis. Retrieval analysis of two modular necks showed corrosion at the
neck-stem taper. Blood cobalt and chromium levels were measured
at a mean of nine months (3 to 28) following surgery. These were
compared with the levels in seven control patients (three men and
four women) with a mean age of 53.4 years (32.1 to 64.1), who had
an identical prosthesis and articulation but with a prosthesis that
had no modularity at neck-stem junction. The mean blood levels of
cobalt in the study group were raised at 50.75 nmol/l (5 to 145)
compared with 5.6 nmol/l (2 to 13) in control patients. Corrosion at neck-stem tapers has been identified as an important
source of metal ion release and pseudotumour formation requiring
revision surgery. Finite element modelling of the dual modular stem
demonstrated high stresses at the modular stem-neck junction. Dual
modular cobalt-chrome hip prostheses should be used with caution
due to these concerns.
A 70-year-old man with an uncemented metal-on-polyethylene
total hip prosthesis underwent revision arthroplasty 33 months later
because of pain, swelling and recurrent dislocation. There appeared
to be corrosion and metal release from the prosthetic head, resulting
in pseudotumour formation and severe local soft-tissue destruction.
The corrosion occurred at the junction between the titanium-molybdenum-zirconium-iron
taper and the cobalt-chrome-molybdenum head, but the mechanism was unproven.
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
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
Cobalt chrome alloy is commonly used in joint replacement surgery. However, it is recognised that some patients develop lymphocyte mediated delayed type hypersensitivity (DTH) responses to this material, which may result in extensive bone and soft tissue destruction. Phase 1. United Kingdom: From an existing database, we identified extreme phenotype patient groups following metal on metal (MoM) hip resurfacing or THR:
Background. Pseudotumor or high grade
Introduction. In 2010, a widely used metal-on-metal hip implant was voluntarily recalled from the market by the manufacturer. Our lab performed detailed retrieval analysis of 548 of the explanted devices and 165 periprosthetic tissue specimens. We reported a high degree of variability in the multiple measurements that we performed on the components, including volumetric wear. Other studies using semi-quantitative tissue grading methods to describe the histology of the periprosthetic tissues from metal-on-metal hips have looked for relationships between component wear and histological features. Grammatopoulos et al found higher
Background. Some reports have suggested that debris generated from the head neck taper junction is more destructive than equivalent doses from metal bearing surfaces. Methods. Part 1. We examined the relationship between the source (taper/bearing) and volume of metal debris on Cr and Co concentrations in corresponding blood and hip synovial fluid samples and the observed agglomerated particle sizes in excised tissues using regression analysis of prospectively collected data at a single revision unit. Part 2. We investigated variables most strongly associated with macroscopic soft tissue injury as documented at revision surgery using ordinal logistic regression. Independent variables included source and volume of CoCr exposure, Cr and Co joint fluid concentrations, joint fluid grade,
Introduction. The utilization of lymphocyte transformation testing (LTT) has increased for diagnosing metal sensitivity associated with TKA, but its validity for the diagnosis of TKA failure due to an immune reaction has not been established. Methods. We performed a retrospective study of 27 well-fixed, aseptic primary TKAs with persistent pain and/or stiffness, revised by a single, experienced surgeon for suspected metal allergy to nickel based on a positive LTT. Periprosthetic tissue samples obtained at the time of revision surgery were scored using the aseptic lymphocytic vasculitis-associated lesion (ALVAL) scoring system. Results. Eight patients were categorized as mildly reactive, 8 reactive, and 11 highly reactive to nickel by LTT. The predominant findings on routine histology were fibrosis and varying degrees of lymphocytic infiltration in 17/27 (63%) of the cases. The average
Hip resurfacing may be a useful surgical procedure when patient selection is correct and only implants with superior performance are used. In order to establish a body of evidence in relation to hip resurfacing, pseudotumour formation and its genetic predisposition, we performed a case-control study investigating the role of HLA genotype in the development of pseudotumour around MoM hip resurfacings. All metal-on-metal (MoM) hip resurfacings performed in the history of the institution were assessed. A total of 392 hip resurfacings were performed by 12 surgeons between February 1st 2005 and October 31st 2007. In all cases, pseudotumour was confirmed in the preoperative setting on Metal Artefact Reduction Sequencing (MARS) MRI. Controls were matched by implant (ASR or BHR) and absence of pseudotumour was confirmed on MRI. Blood samples from all cases and controls underwent genetic analysis using Next Generation Sequencing (NGS) assessing for the following alleles of 11 HLA loci (A, B, C, DRB1, DRB3/4/5, DQA1, DQB1, DPB1, DPA1). Statistical significance was determined using a Fisher's exact test or Chi-Squared test given the small sample size to quantify the clinical association between HLA genotype and the need for revision surgery due to pseudotumour. Both groups were matched for implant type (55% ASR, 45% BHR in both the case and control groups). According to the
Introduction: Hip Resurfacing has increased in popularity, particularly in young, active patients. However, concerns remain regarding metal ion levels, hypersensitivity leading to aseptic lymphocytic-vasculitis-associated lesions(ALVAL) and AVN. The purpose of this study was to document our experience of revising resurfacing arthroplasty for
Background. Pseudotumours have been associated with metal-on-metal (MoM) hip replacements. We define it as a solid mass which may have cystic components that is neither neoplastic nor infectious in aetiology. The cause of a pseudotumour is not fully understood but could be due to excessive wear, metal hypersensitivity or due to an as-yet unknown cause. Aim. We present the retrieval analysis of early failure MoM hips revised for pain, loosening or a symptomatic mass. Tissues and implants were examined for the possible causes of failure and pseudotumour formation. Corrosion as a potential new cause for pseudotumour formation will be presented. Methods. A group of 16 MoM hip replacements were collected for retrieval analysis. Six of which had a pseudotumour. An Artificial Hip Profiler (Redlux Ltd) was used to measure wear. Edge loading was determined using the 3D wear data. Tissues were histologically evaluated using a 10-point
Introduction: There are ongoing concerns regarding metal wear debris following the use of metal-on-metal (MonM) bearings for hip surface and total arthroplasty. A Type IV Hypersensitivity reaction to MonM articulations has previously been identified (aseptic lymphocyte dominated vasculitis associated lesion, ALVAL) but little is known of its incidence, diagnosis or management. Persisting groin pain in MonM patients may be undiagnosed
Metal-on-metal (MOM) hip resurfacings release chromium and cobalt wear debris into the surrounding joint. The hip tissue taken from failed MOM hips shows specific histological features including a subsurface band-like infiltrate of macrophages with particulate inclusions, perivascular lymphocytic infiltrate and fibrin exudation. This tissue response has been called Aseptic Lymphocytic Vasculitis Associated Lesion (ALVAL). There is a recognised carcinogenic potential associated with hexavalent chromium and epidemiological data from first generation MOM arthroplasties may suggest an increased incidence of haematological malignancy. The
Background:. Higher than expected revision rates have been observed in large bearing metal-on-metal total hip replacements. We have introduced a metal on metal hip screening clinic at our unit and report the results. Methods:. All patients who had a metal-on-metal total hip replacement implanted at our unit were recalled to clinic. Screening consisted of clinical examination, Oxford hip score, radiographs, MARS MRI and serum cobalt/chromium ion levels. MRI scans were graded (Norwich Classification) by a single consultant radiologist who was blinded to the history, examination, and metal levels. Patients were sub-classified into 6 groups, which determined further follow up and were either entered into a regular screening programme or referred to a revision arthroplasty surgeon for a decision on whether revision was required. Results:. A total of 278 patients were identified. Four patients had moved away, 2 refused follow-up and 1 patient had died. This left 271 patients in our cohort, having 299 metal-on-metal hip replacements with a M:F ratio of 1.5:1 and a mean age of 61.9 years (29–87). 59 (21.8%) patients complained of a recent deterioration in symptoms. Sixty seven (24.7%) patients had an abnormal xray appearance of their hip replacement (inclination >50 degrees, loosening, or migration of prosthesis). Of the 232 hips which underwent MARS MRI, 118 (50.9%) were group A (normal appearance), 66 (28.4%) C1 (mild MOM disease), 31 (13.4%) C2 (moderate MOM disease), and 17 (7.3%) C3 (severe MOM disease). One hundred and seventeen (38.9%) had a substantial fluid collection around the hip. Serum cobalt/chromium metal ions were raised in 135 patients (49.5%), 46 of which had one (8.8%) or both (8%) above 7 ppb (chromium >134 nmol/L, cobalt > 119 nmol/L). One hundred and forty nine patients (55%) remained under review in the MOM clinic and 122 (45%, 148 hip replacements) were referred to a revision surgeon for specialist opinion. Of these 21 hips (14.2%) have been revised and a further 14 hips (9.5%) are awaiting revision. In total 64 hips (21.3% of all large head metal on metal hips implanted in our unit) have been revised with a further 22 (7.3%) listed for revision. Of these, 13 were histologically proven to be an