Aseptic Lymphocyte Dominated Vasculitis-Associated Lesion Resulting From Trunnion Corrosion in a Cobalt-Chrome Unipolar Hemiarthroplasty

doi:10.1016/j.arth.2012.04.010

The Journal of Arthroplasty

Volume 28, Issue 1, January 2013, Pages 196.e11-196.e14

https://doi.org/10.1016/j.arth.2012.04.010 Get rights and content

Abstract

Most of the published descriptions of adverse soft tissue reactions that have been reported in the context of a metal-on-metal articulation have been in cases of total hip arthroplasty or resurfacing arthroplasty. Recently, several case reports have been published describing aseptic lymphocyte dominated vasculitis-associated lesions (ALVAL) in metal-on-polyethylene. To our knowledge, there has not been a description of a similar, aggressive reaction secondary to metal debris from the head-neck junction of a unipolar hemiarthroplasty component. In this case report, we describe a patient with a catastrophic failure of a unipolar hip hemiarthroplasty, secondary to aggressive osteolysis and an inflammatory mediated immunological reaction to metal debris.

Section snippets

Case Report

In 2006, after a trip and fall, our patient was diagnosed with a right femoral neck fracture. Two days after admission, he received a right hip, unipolar hemiarthroplasty (Stryker Accolade titanium stem; Unipolar Cobalt Chrome Head and adapter sleeve, Stryker Orthopaedics, Mahwah, NJ). There were no reported complications. He did well until December of 2008, when he began to complain of lower back pain, radiating into his lower extremities. Anteroposterior (AP) pelvis and right hip radiographs

Discussion

Recently, there have been several case reports describing ALVAL type immunologic reactions in metal-on-polyethylene bearings 1, 2, 3. Mao et al described the case of a 71 year old woman who developed a pseudotumor secondary to femoral head-neck corrosion 7 years after a conventional non-cemented metal-on-polyethylene total hip arthroplasty (THA) for osteoarthritis [4]. Walsh et al described the case of a 79-year-old man who received a non-cemented metal-on-polyethylene THA and who presented 21

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Cited by (27)

In vivo corrosion on retrieved hip endoprostheses and in vitro effects of corrosion products on bone mineralization
2023, Bone
In vivo corrosion of modular endoprostheses remains a great concern, as the release of heavy metal ions can impair the implant's service life and the wellbeing of the patient. The detailed corrosion mechanisms that occur in vivo are so far not completely understood. In this context, the effects of implant released cobalt (Co) and chromium (Cr) ions on osteoblast mineralization and gene expression have not been investigated extensively.
This comprehensive study aimed at furthering the understanding of in vivo implant corrosion from the clinical signs via prosthesis retrievals and histology of the synovial membranes down to the molecular processes instigated by corrosion products and its effects on bone mineralization. A detailed in vivo failure analysis was performed investigating 22 retrieved hip endoprostheses from different manufacturers and taper material combinations. The aim was to find a correlation of taper damage and especially corrosion to susceptible biomedical alloys and its effect on periprosthetic tissue as well as the clinical implant performance with regard to revision diagnosis and presence of radiolucent lines (RLL). A second part investigated the effects of Co and Cr ions on the in vitro mineralization process of osteoblasts. Cell cultures were exposed to relevant concentrations of CoCl₂ and CrCl₃ (0 μM, 100 μM, 200 μM) with and without addition of phosphate. Mineralization behavior was analyzed with Alizarin Red assay and Von Kossa staining of calcium depots, alkaline phosphatase activity of osteoblasts and gene expression was analyzed with real time quantitative PCR.
The retrieval study provides evidence of in vivo fretting and crevice corrosion on all metallic tapers combined with either ceramic or metal femoral heads. Within the modular taper junctions, selective dissolution of the α phase occurred in wrought TiAl6V4 alloys, and etching of the fine-grained wrought CoCr28Mo6 alloy implants was observed in formed crevices. In addition, significant amounts of wear particles and corrosion products were detected in retrieved synovial membranes. An increased risk for the occurrence of a RLL in the proximal zones was determined for patients with a corroded mixed metal taper.
Whereas Co ions have hardly any effects on mineralization, Cr ions cause a significant concentration dependent decrease in mineralization rate of osteoblasts. However, this effect is alleviated by addition of a phosphate source. Our data reveal that Cr ions depleted dissolved phosphates by forming an insoluble complex (CrPO₄), which inhibits the phosphate dependent mineralization process. No significant effect of the heavy metal ions on osteoblast activity by means of alkaline phosphate activity as well as on gene expression is determined.
This study broadens the understanding of in vivo corrosion of metallic modular implants and its clinically relevant effects on mineralization. Based on these findings, in vivo corrosion of CoCr28Mo6 endoprostheses should be limited to avoid inhibitory effects of Cr³⁺ on bone mineralization which can contribute to premature implant failure.
Articulation of an alumina-zirconia composite ceramic against living cartilage – An in vitro wear test
2020, Journal of the Mechanical Behavior of Biomedical Materials
Citation Excerpt :
However, clinical outcomes are mixed, ranging from reports of comparable survivorships of CoCrMo-based hemiarthroplasty to THA (Pace et al., 2013), to reports of considerable cartilage degeneration proportional to time in situ (Dalldorf et al., 1995). Furthermore, issues with metal-on-metal hip bearings and modular taper joints leading to severe tissue reaction and degradation, such as aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL), have brought to the fore the limitations of CoCrMo alloys as implant materials (Chen and Thouas, 2015; Khair et al., 2013). Ceramics are an attractive alternative to CoCrMo alloys.
There is interest in minimally invasive solutions that reduce osteoarthritic symptoms and restore joint mobility in the early stages of cartilage degeneration. The aim of the present study was to evaluate an alumina-zirconia composite (AZC) as a counterface for articulation against live cartilage explants in comparison to the clinically relevant cobalt-chromium (CoCrMo) alloy.
A four-station bioreactor designed to articulate against living tissue in an incubator was used for testing. Twelve 32 mm AZC and twelve 32 mm CoCrMo femoral heads with equal surface roughness made up both test groups. Each head articulated against a cartilage disk harvested from stifle joints of 24-week old steers. Test samples and free-swelling control cartilage samples were cultured in Mini ITS medium. Testing was conducted 3 h daily over 10 days applying a contact load of approximately 2 MPa. PG/GAG and hydroxyproline were analyzed using biochemical assays. Additionally, chondrocyte survival and Mankin score analyses were performed on histological slides.
Cells stayed alive during the course of the experiment, with cell survival values close to 80% at test completion in the superficial zone. There was no significant difference between AZC and free-swelling control tissue. However, cell count values were inferior for CoCrMo (p = 0.003). Tested tissue suffered mostly structural abnormalities. The PG/GAG content in medium was not different between CoCrMo and AZC (p = 0.315); however, the hydroxyproline release into medium was nearly 30% higher for CoCrMo (p = 0.024).
Based on average values, AZC induces less cell and tissue damage than CoCrMo. However, only the hydroxyproline measurements reached statistical significance, partially due to substantial scatter within both groups.
Future Frontiers in Shoulder Arthroplasty and the Management of Shoulder Osteoarthritis
2018, Clinics in Sports Medicine
Does the Additional Articulation in Retrieved Bipolar Hemiarthroplasty Implants Decrease Trunnionosis Compared to Total Hip Arthroplasty?
2018, Journal of Arthroplasty
Trunnionosis at the modular head-neck taper interface in metal-on-polyethylene total hip arthroplasty (MoP THA) has been shown to occur, and represents a potential mode of MoP THA failure. The purpose of the present investigation is to elucidate differences in fretting and corrosion at the head-neck taper interface of prostheses retrieved from bipolar hemiarthroplasty (BH) and MoP THA.
A retrieval analysis of BH and MoP THA prostheses featuring a single taper design from a single manufacturer and in vivo for a minimum 2 years was performed. Fifteen femoral heads of 28-mm diameter and corresponding femoral stems retrieved from BH were compared with MoP THA implants matched based on time in vivo and head length (28 mm, −3 mm to 28 mm, +8 mm). Fretting and corrosion damage scoring was completed under stereomicroscopic visualization.
Femoral head bore tapers retrieved from BH exhibited decreased overall fretting (P = .02), when compared to those retrieved from MoP THA. Total corrosion scores for all retrieved implants were positively correlated with implantation time (ρ = 0.54, P < .02).
Femoral heads retrieved from BH exhibit decreased fretting damage compared to those retrieved from MoP THA. The added articulation in BH implants may decrease torque produced at the head-neck taper junction, thereby decreasing fretting. Increased fretting damage in implants from MoP THA is not associated with increased corrosion in 28-mm heads of this taper design. The longer a BH or MoP THA prosthesis is implanted, the greater the risk of damage due to corrosion.
Corrosion and adverse tissue reaction after modular unipolar hip hemiarthroplasty
2017, Arthroplasty Today
Modern unipolar hip hemiarthroplasty, commonly used for displaced femoral neck fracture, is now modular, with both a variable length cobalt-chromium adapter-sleeve and large femoral head. Patients with these modular components may develop symptomatic trunnion corrosion, with elevated serum metal levels. We report the case of an 82-year-old woman, 5.5 years after a modular unipolar hip hemiarthroplasty, who presented with a 4-month history of hip pain and limp. Evaluation showed elevated serum cobalt and chromium levels and an acetabular cyst. At revision, fluid, tissue, and gross inspection were consistent with trunnion corrosion. The hip was revised with a ceramic head and dual mobility acetabular component, with a good result at 1 year. The designs of commercially available, modern unipolar hip hemiarthroplasty prostheses are reviewed.
Cardiac transplant due to metal toxicity associated with hip arthroplasty
2017, Arthroplasty Today
Citation Excerpt :
There are well-documented reports of cobalt (Co) toxicity and its effects on the body [1,2]. Local accumulation can lead to local inflammatory responses, metallosis, and tissue lesions [3-7]. Systemic damage may include the respiratory system, the endocrine system, the nervous system and the cardiovascular system (directly affecting myocardium) [2,7-10].
Concerns regarding metal-on-metal (MoM) bearing couples in total hip arthroplasty are well documented in the literature with cobalt (Co) and chromium (Cr) toxicity causing a range of both local and systemic adverse reactions. We describe the case of a patient undergoing cardiac transplantation as a direct result of Co and Cr toxicity following a MoM hip replacement. Poor implant positioning led to catastrophic wear generating abundant wear particles leading to Co and Cr toxicity, metallosis, bony destruction, elevated metal ion levels, and adverse biological responses. Systemic symptoms continued for 3 years following cardiac transplantation with resolution only after revision hip arthroplasty. There was no realization in the initial cardiac assessment and subsequent transplant workup that the hip replacement was the likely cause of the cardiac failure, and the hip replacement was not recognized as the cause until years after the heart transplant. This case highlights the need for clinicians to be aware of systemic MoM complications as well as the importance of positioning when using these prostheses.

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: The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2012.04.010.

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Case ReportAseptic Lymphocyte Dominated Vasculitis-Associated Lesion Resulting From Trunnion Corrosion in a Cobalt-Chrome Unipolar Hemiarthroplasty

Abstract

Section snippets

Case Report

Discussion

Incidence of metal sensitivity in patients with total joint replacements

Br Med J

Metal sensitivity as a cause of bone necrosis and loosening of the prosthesis in total joint replacement

J Bone Joint Surg Br

Metallosis after contemporary metal-on-metal total hip arthroplasty. Five to nine-year follow-up

J Bone Joint Surg Am

Case Report
Aseptic Lymphocyte Dominated Vasculitis-Associated Lesion Resulting From Trunnion Corrosion in a Cobalt-Chrome Unipolar Hemiarthroplasty