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. 2020 Jan-Feb;11(1):165-170.
doi: 10.1016/j.jcot.2019.04.010. Epub 2019 Apr 18.

Severe metallosis-related osteolysis as a cause of failure after total knee replacement

Khaled Hamed Salem  1   2   3 , Norbert Lindner  2 , Markus Tingart  3 , Alyaa Diaa Elmoghazy  2   3
Affiliations

Severe metallosis-related osteolysis as a cause of failure after total knee replacement

Khaled Hamed Salem et al. J Clin Orthop Trauma. 2020 Jan-Feb.

Abstract

Background: Metallosis is a syndrome of metal-induced synovitis caused by friction between two metal surfaces. In contrast to the hip joint after resurfacing arthroplasty or metal-on-metal (MoM) total hip replacement, metallosis of the knee is extremely rare.

Materials: We describe 4 patients who underwent revision total knee replacement because of disabling pain and implant loosening after a mean time of 21 (range: 13-30) years of knee replacement surgery. They were all females with a mean age of 79 (range: 75-82) years. Septic loosening was excluded through microbiological examination and synovial fluid analysis.

Results: Direct metal-on-metal contact at the tibiofemoral interface was confirmed intraoperatively in all cases. All knees showed severe metallosis with advanced osteolysis and pseudotumor formation. In one knee there was a complete fracture of the tibial tray. All patients had a one-stage revision surgery with implant removal, profound synovectomy and implantation of a constrained modular revision knee system. Long modular stems with offset adapters, wedges and/or blocks were used in all cases.

Conclusion: Metallosis-associated osteolysis should be suspected in cases with radiologically evident polyethylene wear after knee replacement. Recognizing that revision arthroplasty is very technically demanding in such cases, surgeons should have a back-up with modular revision components and a ready access to reconstructive options at this revision setting.

Keywords: Arthroplasty; Metal on metal; Metallosis; Polyethylene wear; Revision total knee replacement.

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Figures

Fig. 1
Fig. 1
A case of severe metallosis of the knee joint following fracture of the tibial tray and MoM contact showing the typical radiographic signs (bubble and cloud sign, metal lines and gross metal debris) 20 years after TKA. Revision was done using an RT-Plus system (Smith & Nephew, Memphis, TN).
Fig. 2
Fig. 2
A case of metallosis due to complete wear of the posteromedial part of the inlay with joint subluxation 13 years after TKA. Revision was done using an RT-Plus system with 10 mm tibial augmentation block (Smith & Nephew, Memphis, TN).
Fig. 3
Fig. 3
A case of advanced metallosis with bone loss and metal debris due to MoM contact with aseptic loosening of a unicondylar knee replacement. Revision was done using an RT-Plus system (Smith & Nephew, Memphis, TN).
Fig. 4
Fig. 4
A case of metallosis due to MoM contact at the tibiofemoral and patellofemoral articulation 30 years after TKA. Revision was done using a Legion Revision Knee system (Smith & Nephew, Memphis, TN).
Fig. 5
Fig. 5
Intraoperative photographs of the last case showing dark black staining of the synovial tissues and advanced osteolysis with holes filled with metal debris underneath all prosthetic components.
Fig. 6
Fig. 6
Retrieved implants showing linear scratches on the femoral component and PE-wear of the metal-backed tibial and patellar components.
Fig. 7
Fig. 7
Microscopic picture of metallosis-associated synovitis from the last case.
See this image and copyright information in PMC

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