Metal wear debris generation in primary total knee arthroplasty: is it an issue?

Abstract

More durable total knee arthroplasties (TKAs) are needed, due to the rising life expectancy, the higher activity levels of patients and the growing concerns about aseptic loosening being caused by metal hypersensitivity. In response, different hypoallergenic metal coatings have been developed for TKAs. How- ever, possible adverse effects of these different metals (cobalt-chromium-molybdenum, zirconium, titanium and tantalum) have been neglected. The aim was to summarize the local and systemic adverse effects (including metal hypersensitivity), survival ratios, patient-reported outcome measures (PROMs) and the plasma metal ion concentrations of the different TKA coatings. A literature search on PubMed and EMBASE was performed. In total, 15 studies were found eligible. Common adverse effects of TKA were infection, loosening, pain, instability and hyper- coagulation disorders. Serious adverse effects related to TKA implants were not reported. The survival ratios and patient-reported outcome measures seem to confirm these good results. In contrast with chromium and cobalt, no significant differences were reported in the nickel, molybdenum and titanium concentrations. No significant differences between the hypoallergenic and standard TKA implants were found in terms of adverse effects, survival ratios and PROMs. A causal relationship between the common adverse effects and the different metals is unlikely. Due to the heterogeneity of the TKA implants used, no firm conclusions could be made. Further research with longer follow-up studies are needed to find possible adverse effects and differences. Thus far, the hypoallergenic implants seem to perform equal to the standard implants.

Interaction of Ceramic Implant Materials with Immune System

“…Data on the resistance to wear of metal implants is variable, and metal implants are also susceptible to corrosion, which also leads to the formation of immunogenic particles. Metal wear occurs due to displacement of surface material and detachment of debris particles, metal corrosion is the destruction of metals as a result of an oxidation reduction process [ 83 , 84 , 85 , 86 , 87 , 88 ].…”

Modern Coatings in Knee Arthroplasty

“…In standard TKA implants, this is not a matter of concern. Several studies have investigated metal ion concentrations in standard and coated TKA [16]. Although a relevant reduction of metal ion release has been reported in-vitro [17], there have been no relevant differences in-vivo.…”

“…As a result, an osteolytic activity at the implant-bone interface occurs, resulting in a loosening of the implant components. This inflammatory response is dependent on the amount of wear particles, as well as their type, size and shape [16,22,[41][42][43][44][45]. For this reason, younger and more active patients that generate more wear particles during a longer period of time, are at a higher risk of revision due to aseptic loosening and wear [46].…”

Mild aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL)-type reactions also present in patients with failed knee prostheses

“…Recently, however, interest has arisen over whether ARMD could be one aetiological factor causing unexplained pain and effusion after knee arthroplasty. 9 ARMD is an umbrella term that describes the macroscopic and microscopic findings, such as soft-tissue necrosis, inflammation, and inflammatory masses known as a pseudotumour, seen in these patients. Aseptic lymphocyte-dominated vasculitis-associated lesions (ALVALs) describe the histological effect of lymphocytic infiltration, sometimes accompanied by a pseudotumour.…”

“…Recently, however, interest has arisen over whether ARMD could be one aetiological factor causing unexplained pain and effusion after knee arthroplasty. 9 …”