Early Post-operative Rises in Serum Metal Ion Levels in Total Hip Arthroplasty
A Prospective Cohort Study
Keywords:Trunnionosis, Arthroplasty, Cobalt, Chromium, femoral offset, Femoral head size
Background: Serum Cobalt (Co) and Chromium (Cr) forms part of the diagnostic process for metallosis following Total Hip Arthroplasty (THA). While knowledge exists on longer term metal ion levels, expected early post-operative rises in serum Co and Cr in Metal-on-Polyethylene (MoP) THAs are currently unknown. This study aims to describe early rises in serum Co and Cr at 6 months post-operatively.
Methods: A prospective cohort study of 100 consecutive patients with an uncemented titanium stem from a single THA manufacturer was performed. Patients had either a metal (n=50) or ceramic (n=50) head articulating with a highly cross-linked polyethylene. Serum Co and Cr levels were measured 6 months post-operatively. Analysis compared mean values between groups and to determined baseline levels. Subgroup analysis investigated the effect of femoral head size and offset on metal ion levels.
Results: A mean difference of 2.259 nmol/L (95% CI 0.449-4.069; p=0.015) was found when comparing 6-month serum Co in the metal head group compared to baseline. No significant differences were found in serum Cr (p=0.943). Mean serum Co levels were higher in the MoP group compared to the CoP (Ceramic-on-Polyethylene) comparator group (p=0.012). There were no differences in serum Cr (p=0.976). Variations in femoral head size and offset did not impact metal ion levels.
Conclusion: At six months, a higher magnitude of serum Co exists in metal heads when compared to baseline (p=0.015) and to ceramic heads (p=0.012). Further study is required to determine whether serum concentrations of metal ions will continue to increase over time.
Goldberg JR, Gilbert JL, Jacobs JJ, Bauer TW, Paprosky W, Leurgans S. A multicenter retrieval study of the taper interfaces of modular hip prostheses. Clin Orthop. 2002 Aug;(401):149–61.
Porter DA, Urban RM, Jacobs JJ, Gilbert JL, Rodriguez JA, Cooper HJ. Modern Trunnions Are More Flexible: A Mechanical Analysis of THA Taper Designs. Clin Orthop Relat Res. 2014 Dec;472(12):3963–70.
Bosker BH, Ettema HB, van Rossum M, Boomsma MF, Kollen BJ, Maas M, et al. Pseudotumor formation and serum ions after large head metal-on-metal stemmed total hip replacement. Risk factors, time course and revisions in 706 hips. Arch Orthop Trauma Surg. 2015 Mar;135(3):417–25.
Cooper HJ, Della Valle CJ, Berger RA, Tetreault M, Paprosky WG, Sporer SM, et al. 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 19;94(18):1655–61.
Chana R, Esposito C, Campbell PA, Walter WK, Walter WL. Mixing and matching causing taper wear: corrosion associated with pseudotumour formation. J Bone Joint Surg Br. 2012 Feb;94(2):281–6.
Cooper HJ, Urban RM, Wixson RL, Meneghini RM, Jacobs JJ. Adverse Local Tissue Reaction Arising from Corrosion at the Femoral Neck-Body Junction in a Dual-Taper Stem with a Cobalt-Chromium Modular Neck: J Bone Jt Surg-Am Vol. 2013 May;95(10):865–72.
Weiser MC, Lavernia CJ. Trunnionosis in Total Hip Arthroplasty: J Bone Jt Surg. 2017 Sep;99(17):1489–501.
Whitehouse MR, Endo M, Zachara S, Nielsen TO, Greidanus NV, Masri BA, et al. Adverse local tissue reactions in metal-on-polyethylene total hip arthroplasty due to trunnion corrosion: the risk of misdiagnosis. Bone Jt J. 2015 Aug;97-B(8):1024–30.
Hussenbocus S, Kosuge D, Solomon LB, Howie DW, Oskouei RH. Head-Neck Taper Corrosion in Hip Arthroplasty. BioMed Res Int. 2015;2015:1–9.
Mistry JB, Chughtai M, Elmallah RK, Diedrich A, Le S, Thomas M, et al. Trunnionosis in total hip arthroplasty: a review. J Orthop Traumatol Off J Ital Soc Orthop Traumatol. 2016 Mar;17(1):1–6.
Martin JR, Camp CL, Wyles CC, Taunton MJ, Trousdale RT, Lewallen DG. Increased Femoral Head Offset is Associated With Elevated Metal Ions in Asymptomatic Patients With Metal-on-Polyethylene Total Hip Arthroplasty. J Arthroplasty. 2016;31(12):2814–8.
Barlow BT, Ortiz PA, Boles JW, Lee Y-Y, Padgett DE, Westrich GH. What Are Normal Metal Ion Levels After Total Hip Arthroplasty? A Serologic Analysis of Four Bearing Surfaces. J Arthroplasty. 2017;32(5):1535–42.
Dyrkacz RMR, Brandt J-M, Ojo OA, Turgeon TR, Wyss UP. The influence of head size on corrosion and fretting behaviour at the head-neck interface of artificial hip joints. J Arthroplasty. 2013 Jun;28(6):1036–40.
Craig P, Bancroft G, Burton A, Collier S, Shaylor P, Sinha A. Raised levels of metal ions in the blood in patients who have undergone uncemented metal-on-polyethylene Trident-Accolade total hip replacement. Bone Jt J. 2014 Jan;96-B(1):43–7.
Pereira X, Moga I, Harrington M, Patel P, Ismaily S, Noble P. Variables Influencing Tribo-Corrosion Of Modular Junctions In Metal-on-Polyethylene THR. In 2014.
Kurtz SM, Kocagöz SB, Hanzlik JA, Underwood RJ, Gilbert JL, MacDonald DW, et al. Do ceramic femoral heads reduce taper fretting corrosion in hip arthroplasty? A retrieval study. Clin Orthop. 2013 Oct;471(10):3270–82.
White PB, Meftah M, Ranawat AS, Ranawat CS. A Comparison of Blood Metal Ions in Total Hip Arthroplasty Using Metal and Ceramic Heads. J Arthroplasty. 2016;31(10):2215–20.
Kwon Y-M. Evaluation of the Painful Dual Taper Modular Neck Stem Total Hip Arthroplasty: Do They All Require Revision? J Arthroplasty. 2016 Jul;31(7):1385–9.
Berstock JR, Whitehouse MR, Duncan CP. Trunnion corrosion: what surgeons need to know in 2018. Bone Jt J. 2018 Jan;100-B(1_Supple_A):44–9.
Lash NJ, Whitehouse MR, Greidanus NV, Garbuz DS, Masri BA, Duncan CP. Delayed dislocation following metal-on-polyethylene arthroplasty of the hip due to ‘silent’ trunnion corrosion. Bone Jt J. 2016 Feb;98-B(2):187–93.
Malek IA, King A, Sharma H, Malek S, Lyons K, Jones S, et al. The sensitivity, specificity and predictive values of raised plasma metal ion levels in the diagnosis of adverse reaction to metal debris in symptomatic patients with a metal-on-metal arthroplasty of the hip. J Bone Joint Surg Br. 2012 Aug;94(8):1045–50.
Levine BR, Hsu AR, Skipor AK, Hallab NJ, Paprosky WG, Galante JO, et al. Ten-year outcome of serum metal ion levels after primary total hip arthroplasty: a concise follow-up of a previous report*. J Bone Joint Surg Am. 2013 Mar 20;95(6):512–8.
Qurashi S, Chinnappa J, Rositano P, Asha S. SuperPATH® Minimally Invasive Total Hip Arthroplasty - An Australian Experience. Reconstr Rev. 2016 Jul 15;6(2):43–8.
Weiser MC, Chen DD. Revision for taper corrosion at the neck-body junction following total hip arthroplasty: pearls and pitfalls. Curr Rev Musculoskelet Med. 2016 Mar;9(1):75–83.
Devlin JJ, Pomerleau AC, Brent J, Morgan BW, Deitchman S, Schwartz M. Clinical features, testing, and management of patients with suspected prosthetic hip-associated cobalt toxicity: a systematic review of cases. J Med Toxicol Off J Am Coll Med Toxicol. 2013 Dec;9(4):405–15.
Tan SC, Teeter MG, Del Balso C, Howard JL, Lanting BA. Effect of Taper Design on Trunnionosis in Metal on Polyethylene Total Hip Arthroplasty. J Arthroplasty. 2015 Jul;30(7):1269–72.
Campbell PA, Kung MS, Hsu AR, Jacobs JJ. Do retrieval analysis and blood metal measurements contribute to our understanding of adverse local tissue reactions? Clin Orthop. 2014 Dec;472(12):3718–27.
Meftah M, Haleem AM, Burn MB, Smith KM, Incavo SJ. Early corrosion-related failure of the rejuvenate modular total hip replacement. J Bone Joint Surg Am. 2014 Mar 19;96(6):481–7.
Vundelinckx BJ, Verhelst LA, De Schepper J. Taper Corrosion in Modular Hip Prostheses. J Arthroplasty. 2013 Aug;28(7):1218–23.
Walsh CP, Hubbard JC, Nessler JP, Markel DC. Revision of Recalled Modular Neck Rejuvenate and ABG Femoral Implants. J Arthroplasty. 2015 May;30(5):822–6.
Wang S, Zhang S, Zhao Y. A comparison of polyethylene wear between cobalt-chrome ball heads and alumina ball heads after total hip arthroplasty: a 10-year follow-up. J Orthop Surg. 2013 Jul 8;8:20.
Lavernia CJ, Iacobelli DA, Villa JM, Jones K, Gonzalez JL, Jones WK. Trunnion-Head Stresses in THA: Are Big Heads Trouble? J Arthroplasty. 2015 Jun;30(6):1085–8.
Bolland BJRF, Culliford DJ, Langton DJ, Millington JPS, Arden NK, Latham JM. High failure rates with a large-diameter hybrid metal-on-metal total hip replacement. J Bone Joint Surg Br. 2011 May 1;93-B(5):608–15.
Estey MP, Diamandis EP, Van Der Straeten C, Tower SS, Hart AJ, Moyer TP. Cobalt and Chromium Measurement in Patients with Metal Hip Prostheses. Clin Chem. 2013 Jun 1;59(6):880–6.
US Food and Drug Administration. Information about soft tissue imaging and Metal Ion Testing [Internet]. US Food and Drug Administration; 2019 [cited 2019 Mar 23]. Available from: https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/ucm331971.htm
Sampson B, Hart A. Clinical usefulness of blood metal measurements to assess the failure of metal-on-metal hip implants. Ann Clin Biochem Int J Biochem Lab Med. 2012 Mar 1;49(2):118–31.
Jacobs JJ, Skipor AK, Patterson LM, Hallab NJ, Paprosky WG, Black J, et al. 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.
How to Cite
Copyright (c) 2020 Michael Le, Dante Maestri, Bob Jang, Jason Chinnappa, Sol Qurashi
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright and License Agreement:
Authors who publish with the Reconstructive Review agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work. Reconstructive Review follows the Creative Commons Attribution-NonCommercial CC BY-NC. This license allows anyone to download works, build upon the material, and share them with others for non-commercial purposes as long as they credit the senior author, Reconstructive Review, and the Joint Implant Surgery & Research Foundation (JISRF). An example credit would be: "Courtesy of (senior author's name), Reconstructive Review, JISRF, Chagrin Falls, Ohio". While works can be downloaded and shared they cannot be used commercially.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.