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Commentary and Perspective   |    
Tapering Our Focus to the Causes and Correction of Metallosis in Primary Total Hip ArthroplastyCommentary on an article by Brett R. Levine, MD, MS, et al.: “Ten-Year Outcome of Serum Metal Ion Levels After Primary Total Hip Arthroplasty. A Concise Follow-up of a Previous Report”
Kevin L. Garvin, MD1
1 University of Nebraska Medical Center, Omaha, Nebraska
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The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.


Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Mar 20;95(6):e39 1-2. doi: 10.2106/JBJS.L.01687
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Serum metal ion levels associated with primary total hip arthroplasty is a topic of appreciable interest and concern to orthopaedic surgeons. Metal ion levels are elevated in virtually all patients with a total hip implant, but the significance of the elevated metal ions is unclear. Additionally, high serum concentrations of metal ions do not directly correlate with an adverse local tissue response or other adverse response by the host. Patients evaluated in the current investigation had elevated metal ion levels, which the authors believe, and most researchers concur, are primarily associated with corrosion at the femoral head-neck junction1-3. The same group of investigators has recently reported on adverse local tissue response after total hip arthroplasty as a result of metallosis originating from corrosion at the femoral head-neck junction in ten patients who had a metal-on-polyethylene articulation3. The serum cobalt levels were particularly high in this group of patients and were significantly higher than those seen in the asymptomatic group. These adverse local tissue reactions can occur, but the frequency of this problem is exceptionally low; in this series, the ten patients represented only 1.8% of all of the revisions at the authors’ institution, which is a high-volume revision practice that is well attuned to the diagnoses3.
The strengths of the current investigation are numerous, including the length of follow-up of a relatively large number of patients evaluated prospectively by means of measurement of serum cobalt, chromium, and titanium levels throughout the ten years in which the patients were studied. It is interesting to note that the cobalt and chromium levels rose steadily until peaking at the seventh or eighth year after surgery, whereas the titanium levels rose rapidly and peaked at year three before steadily declining. The length of time from surgery until the cobalt and chromium levels peaked correlated with the timing for revision hip surgery, as nine of the ten hips were revised before year seven and the last one (8.9 years) was revised just after that time period3. The manuscript also raises several important questions that are directly relevant to metallosis. Is there a consequence to chronic elevated metal ions in the serum of patients with total hip implants? Can a taper or trunnion and femoral head be engineered to lessen or even eliminate corrosion and subsequent metallosis? Finally, what unique individual patient circumstances or presumed immunologic responses result in the adverse tissue reaction of some but not other patients and can we positively alter the host response4,5?
The investigation has few weaknesses, but critics may raise concern about the number of patients followed. Of the seventy-five patients, metal ion levels were available for only forty patients (53%). The patients were not lost to follow-up but could not be included in the follow-up because of other factors clearly delineated by the authors. Additional limitations of the study are the number of patients who consented to the investigation and the few variables in the stem and taper design. It is possible that other stem and taper designs may yield either higher or lower serum concentrations of metal ions.
The outcome of elevated serum metal ion levels after total hip arthroplasty is well-documented, and the authors will undoubtedly continue to provide us with more information from their research as it becomes available. The present investigation does add one more piece to this very complicated puzzle of metallosis and the host’s response. Surgeons and patients should take comfort in the uncommon frequency of the problem of symptomatic metallosis in patients who have undergone primary total hip arthroplasty.
Jacobs  JJ;  Skipor  AK;  Patterson  LM;  Hallab  NJ;  Paprosky  WG;  Black  J;  Galante  JO. Metal release in patients who have had a primary total hip arthroplasty. A prospective, controlled, longitudinal study. J Bone Joint Surg Am.  1998 Oct;80(  10):1447-58.
 
Jacobs  JJ;  Skipor  AK;  Black  J;  Urban  RM;  Galante  JO. Release and excretion of metal in patients who have a total hip-replacement component made of titanium-base alloy. J Bone Joint Surg Am.  1991 Dec;73(  10):1475-86.
 
Cooper  HJ;  Della Valle  CJ;  Berger  RA;  Tetreault  M;  Paprosky  WG;  Sporer  SM;  Jacobs  JJ. Corrosion at the head-neck taper as a cause for adverse local tissue reactions after total hip arthroplasty. J Bone Joint Surg Am.  2012 Sep;94(  18):1655-61.[CrossRef]
 
Watters  TS;  Eward  WC;  Hallows  RK;  Dodd  LG;  Wellman  SS;  Bolognesi  MP. Pseudotumor with superimposed periprosthetic infection following metal-on-metal total hip arthroplasty: a case report. J Bone Joint Surg Am.  2010 Jul 7;92(  7):1666-9.[CrossRef]
 
Willert  HG;  Buchhorn  GH;  Fayyazi  A;  Flury  R;  Windler  M;  Köster  G;  Lohmann  CH. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am.  2005 Jan;87(  1):28-36.[CrossRef]
 

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References

Jacobs  JJ;  Skipor  AK;  Patterson  LM;  Hallab  NJ;  Paprosky  WG;  Black  J;  Galante  JO. Metal release in patients who have had a primary total hip arthroplasty. A prospective, controlled, longitudinal study. J Bone Joint Surg Am.  1998 Oct;80(  10):1447-58.
 
Jacobs  JJ;  Skipor  AK;  Black  J;  Urban  RM;  Galante  JO. Release and excretion of metal in patients who have a total hip-replacement component made of titanium-base alloy. J Bone Joint Surg Am.  1991 Dec;73(  10):1475-86.
 
Cooper  HJ;  Della Valle  CJ;  Berger  RA;  Tetreault  M;  Paprosky  WG;  Sporer  SM;  Jacobs  JJ. Corrosion at the head-neck taper as a cause for adverse local tissue reactions after total hip arthroplasty. J Bone Joint Surg Am.  2012 Sep;94(  18):1655-61.[CrossRef]
 
Watters  TS;  Eward  WC;  Hallows  RK;  Dodd  LG;  Wellman  SS;  Bolognesi  MP. Pseudotumor with superimposed periprosthetic infection following metal-on-metal total hip arthroplasty: a case report. J Bone Joint Surg Am.  2010 Jul 7;92(  7):1666-9.[CrossRef]
 
Willert  HG;  Buchhorn  GH;  Fayyazi  A;  Flury  R;  Windler  M;  Köster  G;  Lohmann  CH. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am.  2005 Jan;87(  1):28-36.[CrossRef]
 
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