Nearly all orthopaedic surgeons have implanted a cobalt-chromium hip, and most general practitioners have at least one patient with a cobalt-chromium prosthesis on their books. The recent worldwide controversy surrounding metal-on-metal bearings – and increasing concern over the use of metallic biomaterials in general – means that advice on how to manage patients with metal implants is of great interest to these professionals. Specifically, they want to know if there are any diagnostic tests that could be performed to gain clues about implant performance and the risk of local or systemic toxicity. Biomarkers of Hip Implant Function aims to bring together all established and promising new biomarkers and critically evaluate their clinical usefulness. Researchers will benefit from an updated, comprehensive view of the topic to identify underexplored areas. Orthopaedic surgeons and general practitioners will use the book to monitor implant performance and manage their patients. The work may also benefit engineers and joint implant manufacturers by guiding improvements in implant design, and be of interest to regulators and policymakers to inform guidelines on the follow-up of hip implant recipients.
Author(s): Ilona Świątkowska
Publisher: Academic Press
Year: 2023
Language: English
Pages: 279
City: London
Biomarkers of Hip Implant Function
List of contributors
Copyright
Contents
1 Introduction to hip implants and biomarker testing
1.1 Overview of the hip joint
1.1.1 Anatomy of the hip
1.1.1.1 Cartilage
1.1.1.2 Joint capsule and synovial fluid
1.1.1.3 Ligaments
1.1.1.4 Muscles
1.1.1.5 Blood supply and innervation
1.1.2 Hip joint pathologies
1.1.2.1 Osteoarthritis
1.1.2.2 Rheumatoid arthritis
1.1.2.3 Hip dysplasia
1.1.2.4 Avascular necrosis
1.1.2.5 Femoroacetabular impingement
1.1.2.6 Traumatic injuries
1.2 Overview of hip implants
1.2.1 Implant biomaterials
1.2.1.1 Metals
1.2.1.2 Plastic polymers
1.2.1.3 Ceramics
1.2.2 Bone fixation
1.2.3 Implant classification
1.2.4 Evolution of a total hip replacement
1.2.4.1 Implant modularity
1.2.5 The rise and fall of hip resurfacing
1.2.6 Implant degradation
1.2.7 Implant performance
1.2.7.1 Surgeon factors
1.2.7.2 Implant factors
1.2.7.3 Patient factors
1.3 Introduction to biomarkers
1.3.1 Biomarker discovery
1.3.2 Assay validation
1.3.3 Evaluation of clinical validity
1.3.3.1 Sensitivity and specificity
1.3.3.2 Predictive values
1.3.3.3 Likelihood ratios
1.3.3.4 Diagnostic accuracy
1.3.3.5 Receiver operating characteristic curves
1.3.3.6 Diagnostic odds ratios
1.3.4 Characteristics of an ideal biomarker
1.3.5 Biomarkers of hip implant function and toxicity
References
2 Degradation of metal hip implants
2.1 Introduction to metallic biomaterials
2.1.1 Iron-based alloys
2.1.2 Cobalt-based alloys
2.1.3 Titanium-based alloys
2.2 Introduction to tribology
2.2.1 Contact of surfaces
2.2.2 Friction
2.2.3 Wear of materials
2.2.3.1 Abrasive wear
2.2.3.2 Adhesive wear
2.2.3.3 Fretting/fatigue wear
2.2.4 Lubrication
2.2.4.1 Boundary lubrication
2.2.4.2 Fluid-film lubrication
2.2.4.3 Mixed lubrication
2.2.4.4 Lubrication in metal hips
2.3 Introduction to corrosion
2.3.1 Thermodynamics and electrochemistry
2.3.2 Passivity of metallic materials
2.3.3 Types of corrosion
2.3.3.1 Uniform/general corrosion
2.3.3.2 Galvanic corrosion
2.3.3.3 Crevice corrosion
2.3.3.4 Pitting corrosion
2.3.3.5 Intergranular corrosion
2.4 Tribocorrosion
2.5 Modern hip replacements
2.5.1 Sources of degradation
2.5.1.1 Bearing surfaces
2.5.1.2 Modular tapers
2.5.1.3 Stem–cement interface
2.5.2 Adverse reaction to metal debris
2.5.3 Assessing material loss from metal hip implants
2.5.4 Studying metal deposits in tissue
2.5.4.1 Periprosthetic tissue
2.5.4.2 Organ tissue
2.6 Summary and future directions
References
3 Implant metals and their potential toxicity
3.1 Hip implant metals and the human health
3.1.1 Cobalt
3.1.1.1 Toxicokinetics
3.1.1.2 Systemic toxicity
3.1.2 Chromium
3.1.2.1 Toxicokinetics
3.1.2.2 Systemic toxicity
3.1.3 Molybdenum
3.1.3.1 Toxicokinetics
3.1.3.2 Systemic toxicity
3.1.4 Nickel
3.1.4.1 Toxicokinetics
3.1.4.2 Systemic toxicity
3.1.5 Titanium
3.1.5.1 Toxicokinetics
3.1.5.2 Systemic toxicity
3.1.6 Vanadium
3.1.6.1 Toxicokinetics
3.1.6.2 Systemic toxicity
3.1.7 Aluminium
3.1.7.1 Toxicokinetics
3.1.7.2 Systemic toxicity
3.1.8 Reproductive toxicity
3.1.9 Genotoxicity and carcinogenicity
3.2 Metal hypersensitivity
3.3 Local effects of metal debris
References
4 Markers of hip implant degradation: analytical considerations and clinical interpretation
4.1 Introduction
4.2 Mechanisms of implant degradation
4.2.1 Passive corrosion
4.2.2 Galvanic corrosion
4.2.3 Mechanically assisted corrosion
4.2.4 Bearing wear
4.2.5 Abnormal component contact
4.3 Measuring systemic levels of cobalt, chromium, and titanium
4.3.1 Choice of sample type
4.3.1.1 Urine
4.3.1.2 Blood
4.3.2 Specimen collection and storage
4.3.2.1 Urine
4.3.2.2 Blood
4.3.3 Quantification of metal levels
4.3.3.1 Sample preparation
4.3.3.2 Analytical approach
4.3.3.3 Minimising spectral interferences
4.3.3.4 Sources of intra- and inter-laboratory variability
4.3.3.5 The units
4.4 Using systemic metal levels to assess implant degradation and risk of local adverse reactions
4.4.1 Cobalt and chromium
4.4.2 Titanium
4.5 Summary and future directions
References
5 Biomarkers of compromised implant fixation
5.1 Introduction
5.2 Osseointegration of hip implants
5.2.1 Implant design
5.2.1.1 Bioactive coatings
5.2.1.2 Surface properties
Wettability
Chemical composition
Oxide layer thickness
Roughness
5.2.1.3 Porous metals
5.2.2 Patient-related factors
5.2.3 Surgeon-related factors
5.3 Periprosthetic osteolysis and aseptic loosening
5.4 Postoperative measures to stimulate osseointegration and inhibit osteolysis
5.4.1 Rehabilitation and postoperative drugs
5.4.2 Pharmacological inhibition of periprosthetic osteolysis
5.4.3 Biophysical stimulation
5.5 Monitoring patients for signs of periprosthetic osteolysis and aseptic loosening
5.6 Molecular biomarkers of periprosthetic osteolysis and aseptic loosening
5.6.1 Inflammatory markers
5.6.2 Markers of bone turnover
5.6.3 Markers of oxidative stress
5.6.4 Single-nucleotide polymorphisms
5.6.4.1 Cytokines
5.6.4.2 Proteins, receptors, and intracellular mediators
5.6.4.3 Enzymes
5.7 Summary and future directions
References
6 Biomarkers of periprosthetic joint infection
6.1 Introduction
6.2 Periprosthetic joint infection
6.2.1 Pathogenesis and bacterial aetiology
6.2.2 Clinical presentation
6.2.3 Treatment
6.3 Clinical definition of periprosthetic joint infection
6.4 Diagnostic categories
6.4.1 Clinical symptoms
6.4.2 Imaging studies
6.4.3 Blood biomarkers
6.4.3.1 C-reactive protein and erythrocyte sedimentation rate
6.4.3.2 D-dimer
6.4.3.3 Interleukin-6
6.4.3.4 Procalcitonin
6.4.3.5 Fibrinogen
6.4.4 Synovial biomarkers
6.4.4.1 White blood cell count and polymorphonuclear leukocyte percentage
6.4.4.2 Leukocyte esterase
6.4.4.3 Alpha-defensin
6.4.4.4 Calprotectin
6.4.4.5 Synovial C-reactive protein
6.4.4.6 Synovial interleukin-6
6.4.4.7 Synovial interleukin-8
6.4.5 Microbiology
6.4.5.1 Joint aspiration culture
6.4.5.2 Preoperative periprosthetic biopsy culture
6.4.5.3 Intraoperative periprosthetic tissue culture
6.4.5.4 Sonication fluid culture
6.4.6 Histology
6.4.6.1 Gram stain
6.4.7 Molecular techniques
6.4.7.1 Polymerase chain reaction
6.4.7.2 Next-generation sequencing
6.5 Confounding factors
6.5.1 Adverse reaction to metal debris
6.5.2 Inflammatory arthritis
6.5.3 Crystal-induced arthritis
6.6 Summary and future directions
References
7 Hip implants and systemic cobalt toxicity: a comprehensive review with case studies
7.1 Introduction
7.2 Arthroprosthetic cobaltism
7.2.1 Case studies
7.2.1.1 Case study 1
7.2.1.2 Case study 2
7.2.1.3 Case study 3
7.2.1.4 Case study 4
7.2.1.5 Case study 5
7.2.1.6 Case study 6
7.2.1.7 Case study 7
7.2.1.8 Case study 8
7.2.1.9 Case study 9
7.2.1.10 Case study 10
7.2.1.11 Case study 11
7.2.1.12 Case study 12
7.2.1.13 Case study 13
7.2.1.14 Case study 14
7.2.1.15 Case study 15
7.2.1.16 Case study 16
7.2.1.17 Case study 17
7.2.1.18 Case study 18
7.2.2 Mechanisms of cobalt toxicity
7.2.2.1 Induction of oxidative stress
7.2.2.2 Disruption of mitochondrial function
7.2.2.3 Simulation of cellular hypoxia
7.2.2.4 Interference with calcium signalling
7.2.2.5 Displacement of divalent metal cations from metalloproteins
7.2.2.6 Inhibition of iodine uptake
7.2.3 Differential diagnosis
7.2.3.1 Cardiomyopathy
7.2.3.2 Neurotoxic and psychiatric symptoms
7.2.3.3 Thyroid abnormalities
7.2.4 Treatment
7.2.4.1 Revision surgery
7.2.4.2 Chelation therapy
7.2.4.3 Therapeutic plasma exchange
7.2.5 Individual susceptibility to systemic cobalt toxicity
7.2.5.1 Decreased albumin–cobalt binding capacity
7.2.5.2 Kidney disease
7.2.5.3 Nutritional and hormonal deficiencies
7.2.6 Systemic toxicity and free cobalt ion levels
7.3 Summary and future directions
References
8 Clinical guidelines on the use of biomarkers for surveillance of hip replacements
8.1 Introduction
8.2 Evaluating implant wear and risk of local adverse reactions to metal debris in patients with metal-on-metal hips
8.2.1 Circulating cobalt and chromium levels
8.2.2 The decision to revise
8.2.3 Conclusion
8.3 Investigation for systemic toxicity
8.3.1 Circulating cobalt levels
8.3.2 The decision to revise
8.3.3 Conclusion
8.4 Monitoring of patients with titanium-based hip implants
8.4.1 Circulating titanium levels
8.4.2 The decision to revise
8.4.3 Conclusion
8.5 Investigation for periprosthetic infection
8.5.1 Conclusion
8.6 Summary and future directions
References
Index
