Aims. We present a case series of five patients who had revision surgery following magnetic controlled growing rods (MGCR) for early onset scoliosis. Metallosis was found during revision in four out of five patients and we postulated a mechanism for rod failure based on retrieval analysis. Patients and Methods. Retrieval analysis was performed on the seven explanted rods. The mean duration of MCGR from implantation to revision was 35 months (17 to 46). The mean age at revision was 12 years (7 to 15; four boys, one girl). Results. A total of six out of seven rods had tissue metallosis and pseudo-capsule surrounding the actuator. A total of four out of seven rods were pistoning. There were two rods which were broken. All rods had abrasive circumferential markings. A significant amount of metal debris was found when the actuators were carefully cut open. Analytical electron microscopy demonstrated metal fragments of predominantly titanium with a mean particle size of 3.36 microns (1.31 to 6.61). Conclusion. This study highlights concerns with tissue metallosis in MCGR. We recommend careful follow-up of patients who have received this implant. Cite this article: Bone Joint J 2016;98-B:1662–7

INTRODUCTION. Progressive polyethylene wear is associated with the occurrence of osteolysis, which can lead to component loosening and subsequent revision. Massive wear of the polyethylene liner may result in the penetration of the femoral head through the metal shell. Although metallosis after total hip arthroplasty has been well documented in the literature, extensive metallosis with polyethylene wear-through has been only sparsely described. The purpose of the present study was to assess clinical findings and the results of revision total hip arthroplasty in these cases. METHODS. We evaluated seven hips in five patients who underwent revision total hip arthroplasty because of metallosis with polyethylene wear-through. The average age of the patients at the time of hip revision was 70.1 years. There were granulomatous cysts surrounding the hip joint and osteolysis in the greater trochanter or in the acetabulum. Eroded metal shells with worn-through polyethylene were exchanged. Kerboull-type acetabular reinforcement device were used in five hips and GAP cup in two. Distal interlocking femoral stems were used in four hips and extensively porous-coated stems in two. All cases with osteolysis were in addition treated with bulk or morselized allograft bone. The mean duration of follow-up was 3 years. RESULTS. At the time of final follow-up evaluation, none of the hips showed osteolysis. Stable fixation of femoral and acetabular components was achieved in all cases. Bulk allograft bone was resorbed in two cases, but in all other cases grafted bones were united and improve bone stock. CONCLUSIONS. Metallosis with polyethylene wear-through caused severe synovitis and massive osteolysis. Although debridement of the surrounding metallic stained tissue could not be completely done, the clinical result of revision surgery was favorable

Metallosis after a total joint arthroplasty, although uncommon, is a serious complication that may occur. The deposition of metallic wear debris in the joint space may lead to thickening of the synovium and the formation of a thin dark colored film substance. We present 4 cases of metallosis from a total number of 246 total knee arthroplasties that were performed the last 10 years in our department. All patients were females with a mean age of 71.5 years (range 67 to77 years). The main symptoms were pain, swelling, and limited range of motion around the knee joint space. No signs of sinuses or wound drainage were noted. Bone scanning showed increased activity around the prosthesis. Needle joint aspiration and intra-operative wound culture were negative for any microorganism growth. Patients have had 4 types of different implants; AGC, S+G, Kirschner and Rotaglide. Extensive synovectomy and revision of all the implants were done on 3 patients and only the revision of the polyethylene component was done on one patient. We conclude that metallosis is a serious complication that requires surgical treatment. Different diagnostic tests should be also included in order to exclude the possibility of infection. Proper alignment of the implants combined with proper soft tissue balance are 2 important factors to be respected when performing TKA

Purpose: Although hip prosthesis heads made of titanium are no longer implanted to our knowledge, it is important to officially record the failures related to their use. Device monitoring experts can only prove the hazard resulting from these implants if results of human clinical series have clearly described the inconveniences. We found a rich body of literature dating from the end of the eighties that concluded that the rate of wear with the polyethylene lined titanium implants was very low but have found no paper describing the problems related to its use. We report this work to fill the gap. Material and methods: This prospective study included a consecutive series of the first 100 total hip prostheses using the ion-implanted titanium 22.2 mm head (NITRU-VID) implanted between January 30, 1990 and June 19, 1991. There were 45 men and 55 women, 55 right hips and 45 left hips implanted for primary degenerative disease in 92, dysplasia in two and congenital dislocation in six. Mean age at implantation was 60 years (28–82). The same operative technique was used for all patients using the same Atlas-PSM implant. Eleven patients died and six were lost to follow-up. Thus 83 ere retained for analysis with the Postel-Merle-d’Aubigné (PMA) score on the AP and lateral views of the hip. Kaplan-Meier survival curves were established. Results: Eleven patients underwent revision surgery for different causes, metallosis in seven. The delay to revision for metallosis was eight years in two, nine years in one and ten years in four. These cases of metallosis were expressed clinically by moderate pain and minimal radiographic signs: bone defect in the greater trochanter in seven, acetabular lines in three. Four cups loosened, none of the femur components. The diagnosis of metallosis was made at revision in five cases, and on the basis of hip biopsy in two. Metallosis was intense with black coloration of all the tissues. Pathology confirmed the diagnosis; the head were depolished with wear of the upper pole and loss of spherical shape as verified in the laboratory. The 10-year survival was 91.33%. For the 72 patients who did not have revision surgery, only nine still had moderate pain and four limped. There were eleven cases with trochanteric defects in zone 3 requiring close follow-up as this can be an early sign of metallosis. Discussion: This study proves that despite the ion-implantation, the heads wear and lead to metallosis. No metallosis was observed when using the same implants with different heads at a maximal follow-up of 14 years. In an earlier study on the first 100 implants of this type, the 10-year survival was 98.7%. The drop in the 10-year survival from 98.7 to 91.33% can only be explained by the ion-implanted titanium heads. Conclusions: Ion-implanted titanium heads wear and lead to metallosis. Their use is formally contraindicated. Hip biopsy can provide early diagnosis of metallosis

Introduction

There is no doubt that the future of limb lengthening lies with internal lengthening. Complication rates are reduced and patient satisfaction is increased. The evolution of internal lengthening peaked with the dual direction, easily inserted and externally controlled PRECICE Nail. It has excelled in performance in accuracy and satisfaction. Its versatility increased with smaller sizes and increased excursion. A field safety notice was issued was issued in October 2021 by the parent company NuVasive. The advice was monitoring of current cases and a hold on implantation until after a review of process. At the National Orthopaedic Hospital Cappagh we elected to remove all implanted nails and assess the nail integrity and physiological changes associated with implantation.

Metallosis is a combined chemical and toxic reaction which, if the wear of a metal implant is large, may cause extensive reaction of synovial membrane and thus triggering the loosening. We present a case of a 72 year-old man, who underwent to a cemented unicompartimental porous metal coated knee implant because affected by rheumatoid arthritis complicated by osteonecrosis of medial femoral condyle of the knee. Four years after replacement, the patient presented symptoms included moderate swelling, pain, synovitis inability to bear full weight as well as grinding; plain radiographs shows well fixed implant and not finding of loosening of prosthesis; arthroscopy revealed the diagnosis of metallosis. The specimens of synovial tissue were prepared to observation to light and electron microscopy. Total synovialectomy and revison with total knee replacement were successful in relieving the symptoms. Arthroscopy examination revealed a posterior break of tibial component, source of the release of multiple metal beads; we observe alsogray black discoloration of hypertofic and hyperplastic synovium pannus like; metal beads were detected in the joint space soft tissue and were also embedded in the articulating surface of the tibia component. Microscopic examination shows metal debris as black aggregates and a diffuse sheet like proliferation inside histiocytes of villous membrane. Ultrastructural study demonstrate that the presence of metallic fragments, measuring less than 0.3 micron in diameter is predominantly concentrated inside the macrophage’s phagolisosomes. Delivery of large number of metal beads from implant and the release of smallest size metal debris play a pivotal role in the development of a foreign body granulomatous reaction. The failure of unicompartimental prosthesis has been accellerated by unperformed sinoviectomy during the first implant; the cells of synovial membrane are continuosly activated, by wear of implant material, to phagocitate and to secrete inflammatory response

Recent reports about the excellent clinical results of unicondylar knee arthroplasty (UKA; also known as unicompartmental knee arthroplasty), by the minimally invasive approach, have encouraged the adoption of the surgical technique. However, friction between metallic prosthetic components resulting from polyethylene wear may result in the development of metallosis and the use of metal implants has become a huge issue in the worlds recently. Here, we report a case in which a patient underwent UKA and developed metallosis in soft tissues and bone adjacent to an implanted artificial joint three years postoperatively.

Aims: In vitro studies have demonstrated that phagocytosed metal wear particles can lead to osteolysis by osteoclast activation. While others have reported massive metallosis with no loosening of the implant. The incidence of metallosis has remained uncertain so far. The purpose of this prospective study was to assess the incidence of metallosis and explore the correlation between metallosis and the time to revision of total hip replacements, getting additional information of the role of metallosis in aseptic loosening.

Materials and Methods: 72 patients underwent revision of total hip arthroplasty at the authors department from 01/01/2001 to 31/12/2002. All of them were examined for metallosis macroscopically and biopsy was taken from the interfacial membrane for histological analysis. Two subgroups were created from revisions of both cemented and uncemented prostheses. First group was composed of cases if metallosis was either visible during the surgery or high amount of metal particles were found by histology (high-grade metallosis). The other group consisted of cases if metallosis was not visible intraoperatively and only a few metal particles were described by histology (low-grade metallosis). The survivorships of the prostheses were assessed by Kaplan-Meyer statistic analysis.

Results: High-grade metallosis could be detected in 10/42 revisions of cemented (23.8%), and in 12/30 cases of uncemented prostheses(40%). The time from implantation to revision was 88(36–144) months when metal-losis could be observed vs. 122(41–360) months in cases with no metallosis in the cemented group. However there was not significant difference in survival rate of the uncemented prostheses between the metallotic and non-metallotic groups. If only very few metal particles were found, high amount of polyethylene particles were described by histology.

Conclusion: The incidence of high-grade metallosis was higher around uncemented prostheses. The time to revision of cemented prostheses was significantly less if high-grade metallosis was found. Hence it seems like metallosis can have effect on aseptic loosening of cemented prostheses by the large number of metal particles which can make the progress of osteolysis faster resulting in shorter survivorship of the implant. If no high-grade metallosis, but a lot of polyethylene wear were found, then those particles could have the same inductive effect on aseptic loosening.

Aims

To investigate metallosis in patients with magnetically controlled growing rods (MCGRs) and characterize the metal particle profile of the tissues surrounding the rod.

We studied 12 patients (13 elbows) who underwent total elbow replacement (TER) using the Kudo Mk IV or V prosthesis between 1989 and 1997. There were eight females and four males (mean age: 61 years, range: 38–74 years). The diagnosis was Rheumatoid arthritis in 10 patients and osteoarthritis in two patients. In each patient the initial result was classified as either excellent or good. All these patients then reported the recurrence of severe pain at a mean of four years from the time of the primary operation. Radiographic examination demonstrated fracture of the humeral stem in 10 elbows and subluxation of the joint in three elbows. The fractured humeral components were exchanged for long stem components. The three subluxated elbows were found to have undergone delamination and loosening of the ulnar components which were revised. One of these required revision to a linked prosthesis due to bone loss.

In each case metallosis was found involving principally the synovial tissues which were as far as possible excised. Each patient regained a similar range of movement to that following the primary arthroplasty but continues to experience episodes of pain requiring anti-inflammatory medication. This is in contrast to our patients requiring revision procedures for implant loosening or instability who have become pain free.

We conclude that the development of metallosis complicating mechanical implant failure predisposes to persisting symptoms following revision arthroplasty and recommend that this should be undertaken sooner rather than later when mechanical failure is detected.

Between 1989 and 1993, 158 patients with a total of 187 damaged knees underwent TKA using AGC-S prosthesis (Biomet). Of these patients, six required revision surgeries due to metallosis. The average period from the first operation to the revision was 68.0 months (range: 41–97 months). In all six cases, the plain X-rays taken immediately before reoperation, showed sinking of the tibial component. The withdrawn implants showed severe abrasion of the polyethylene used in the posteromedial area. The percent share of the tibial component averaged 90.3% (range: 85.3–93.5%) on the anteroposterior view, and on the lateral view averaged 83.1% (range:76.9–94.0%). The tibial components used for AGC-S type TKA can be characterized by the presence of a rim. In some cases, however, the rim cannot be placed on the tibial cortex, and this obliges the surgeon to select smaller components, resulting in a smaller percent share of the tibial component. The tibial component can sink in such cases. The sinking of the tibial component probably leads to malalignment and joint instability. Furthermore the insert with a flat surface was likely to induce articular instability, thus enhancing the abrasion of the polyeth

Aims

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.

Purpose

Complete wear-out of Polyethylene (PE) liner results in severe metallosis following articulation of the artificial head with the acetabular metal shell. We postulated that an adverse response can be led to surrounding bone tissue and new implant after revision surgery because the amount of PE wear particle is substantial and the metal particles are infiltrated in this catastrophic condition. We evaluated clinical characteristics and the survival rate of revision total hip arthroplasty (THA) performed in patients with severe metallosis following failure of PE liner.

Background: Recent studies have reported early periprosthetic osteolysis in patients who have been treated with a contemporary metal-on-metal total hip arthroplasty and suggested that metal hypersensitivity associated with an immunologic response to metal may be of etiologic importance. We evaluated the results and histologic findings in patients who underwent revision surgery for a failed contemporary metal-on-metal total hip arthroplasty.

Material and Methods: Two hundred and seventeen total hip arthroplasties (SL-Plus stem and Bicon-Plus cup) with a Sikomet metal-on-metal articulation were implanted in one hundred and ninety four consecutive patients and retrospectively reviewed at mean of 77 months postoperatively. Clinical follow up was performed with the Harris hip score and plain radiographic evaluation was performed. Histologic analysis was performed on the periprosthetic tissues of 14 hips that underwent revision arthroplasty.

Results: The mean Harris hip score improved from 45 preoperatively to 96 at final evaluation. Fourteen (6.4%) hips were revised: 9 for aseptic loosening, 2 for technical failure and three for septic failure. Histologic examination of the retrieved periprosthetic tissues from the eleven patients who underwent revision for aseptic loosening or technical failure showed microscopic metallosis and extensive lymphocytic and plasma cell infiltration around the metal debris. With an endpoint of removal of a component with aseptic loosening, endpoint survivorship was 93% for the stem and 98% for the cup respectively.

Conclusions: Our findings are in agreement with recent publications and support the possibility that periprosthetic osteolysis and aseptic loosening in hips with metal-on-metal articulation are possibly associated with hypersensitivity to metal debris. Prospective, comparative randomized long-term studies are necessary to determine the cause(s) of loosening of this particular articulation.

INTRODUCTION

The risk of dislocation in large diameter metal on metal hip replacement is significantly lower than in standard THR. This is due to the increased primary arc, increased jump distance and possibly a suction effect. Our unit has performed over 1500 of these cases with an overall revision rate of <1%. We report a case series of dislocations in 5 large diameter metal on metal hips undertaken at our unit.

INTRODUCTION

The advantages of large diameter metal on metal total hip arthroplasty (MoM THA) and hip resurfacing arthroplasty are decreased wear rate, preservation of bone stock, anatomical restoration and enhanced stability. Large amounts of metal wear particles and metal ions are released which may induce adverse reactions including local soft tissue toxicity, hypersensitivity reactions, bone loss and risk of carcinogenesis. Aseptic loosening can be the result of a peri-prosthetic osteolysis generated as a result of a biological response to particulate wear debris.

No reports in the literature exist as to whether circulating levels of Chromium (Cr) and Cobalt (Co) decrease upon removal of a symptomatic large diameter MoM implant or whether levels remain high due to the effect of metal ions debris left behind in the soft tissues after revision surgery.

We present two patients with swelling of the groin following metal-on-metal total hip replacement without radiological signs of component loosening. MRI in both patients showed a round shaped intrapelvic lesion ventral to the femoral head. During surgery we found cystic structures filled with fluid and necrotic masses. After resection the metal head and insert were changed to a ceramic head and a polyethylene insert.

Although two different kinds of CoCrMo alloy were used in the metal-on-metal THR (Sikomet: low carbon content-Metasul: high carbon content) histopathological analysis in both cases showed typical morphological signs of hypersensetively determined inflammation. Despite the distinct soft tissue reaction bony component integration was unaffected.

In our opinion open resecion of the cystic lesion and changing of the metal-on-metal articulation is the treatment of choice.

As we do not have any reliable testing for clinical use to predict a hypersensitive reaction to metal wear after implantation of metal-on-metal THR this articulation surface should not be used in cases where allergy to metal is suspected.

Symptomatic cobalt toxicity from a failed total hip replacement is a rare but devastating complication. It has been reported following revision of fractured ceramic components, as well as in patients with failed metal-on-metal articulations. Potential clinical findings include fatigue, weakness, hypothyroidism, cardiomyopathy, polycythaemia, visual and hearing impairment, cognitive dysfunction, and neuropathy. We report a case of an otherwise healthy 46-year-old patient, who developed progressively worsening symptoms of cobalt toxicity beginning approximately six months following synovectomy and revision of a fractured ceramic-on-ceramic total hip replacement to a metal-on-polyethylene bearing. The whole blood cobalt levels peaked at 6521 µg/l. The patient died from cobalt-induced cardiomyopathy. Implant retrieval analysis confirmed a loss of 28.3 g mass of the cobalt–chromium femoral head as a result of severe abrasive wear by ceramic particles embedded in the revision polyethylene liner. Autopsy findings were consistent with heavy metal-induced cardiomyopathy.

We recommend using new ceramics at revision to minimise the risk of wear-related cobalt toxicity following breakage of ceramic components.

Cite this article: Bone Joint J 2013;95-B:31–7.

Metallosis is a rare cause of failure after total knee replacement and has only previously been reported when there has been abnormal metal-on-metal contact. We describe 14 patients (15 knees) whose total knee replacement required revision for a new type of early failure caused by extensive metallosis. A modification of a cementless rotating platform implant, which had previously had excellent long-term survival, had been used in each case. The change was in the form of a new porous-beaded surface on the femoral component to induce cementless fixation, which had been used successfully in the fixation of acetabular and tibial components. This modification appeared to have resulted in metallosis due to abrasive two-body wear. The component has subsequently been recalled and is no longer in use. The presentation, investigation, and findings at revision are described and a possible aetiology and its implications are discussed