Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Sep;7(3):247-261.
doi: 10.1007/s40883-021-00222-1. Epub 2021 Jul 29.

The Mechanism of Metallosis After Total Hip Arthroplasty

Affiliations

The Mechanism of Metallosis After Total Hip Arthroplasty

Chinedu C Ude et al. Regen Eng Transl Med. 2021 Sep.

Abstract

Metallosis is defined as the accumulation and deposition of metallic particles secondary to abnormal wear from prosthetic implants that may be visualized as abnormal macroscopic staining of periprosthetic soft tissues. This phenomenon occurs secondary to the release of metal ions and particles from metal-on-metal hip implants in patients with end-stage osteoarthritis. Ions and particles shed from implants can lead to local inflammation of surrounding tissue and less commonly, very rare systemic manifestations may occur in various organ systems. With the incidence of total hip arthroplasty increasing as well as rates of revisions due to prosthesis failure from previous metal-on-metal implants, metallosis has become an important area of research. Bodily fluids are electrochemically active and react with biomedical implants. Particles, especially cobalt and chromium, are released from implants as they abrade against one another into the surrounding tissues. The body's normal defense mechanism becomes activated, which can elicit a cascade of events, leading to inflammation of the immediate surrounding tissues and eventually implant failure. In this review, various mechanisms of metallosis are explored. Focus was placed on the atomic and molecular makeup of medical implants, the component/surgical associated factors, cellular responses, wear, tribocorrosion, joint loading, and fluid pressure associated with implantation. Current treatment guidelines for failed implants include revision surgery. An alternative treatment could be chelation therapy, which may drive future studies.

Keywords: Arthroplasty; Biomedical implants; Biotribocorrosion; Mechanism; Metallosis.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
a Intraoperative pseudo-tumor in hip arthroplasty. Intraoperative pseudo-tumor showing gross intraoperative findings of extensive pseudo-tumor and dark stained synovium. Pathology reported as fibrovascular tissue and fragments of bone with marked metal wear debris. Thomas et al., 2019, with permission to re-print from Elsevier. b Microscopic findings of pseudo-tumor indicating metallosis. Microscopic pathologic findings of pseudo-tumor demonstrating significant metallosis. Thomas et al., 2019, with permission to re-print from Elsevier. c Intraoperative photograph of black staining in knee arthroplasty. 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. Salem et al., 2020, with permission to re-print from Elsevier. d Microscopic photograph of metallosis from knee arthroplasty. Microscopic picture showing metallosis-associated synovitis from the wear-related complications. Salem et al., 2020, with permission to re-print from Elsevier
Fig. 2
Fig. 2
a Factors influencing tribocorrosion. The schematic diagramof the tribocorrosion system depicting the various components that act in synergy to cause the irreversible transformation of materials, functions, and status as a result of concurrent mechanical, chemical and electrochemical interactions between surfaces in relative motion. b Concept of biotribocorrosion. The schematic diagram of the biotribocorrosion phenomena that deals with mechanical loading and electrochemical reactions occurring between elements of the tribological system when exposed to biological environments, like body fluid
Fig. 3
Fig. 3
The contributing factors to metallosis. A schematic diagram showing the various contributing factors that act alone or in a combined effect on implants and body fluid systems to induce metallosis
Fig. 4
Fig. 4
NF-kB activation effect. The schematic diagram showing the response of NF-kB activation by wear debris. NF-kB signaling can be activated in macrophages and osteoclasts by exposure to wear particles. Under the influence of Th1 and Th2 cell-derived cytokines, primary macrophages (M0) assume two distinct phenotypes known as classically activated macrophages (M1) and alternatively activated macrophages (M2). M1 activation can be induced by IFN-g secreted by NK or Th1 cells, TNF-a receptors, implant/wear debris, DAMPs, and PAMPs. Working in synergy, IFN-g and TNF-a signal Janus kinase transducer and activator of transcription (JAK-STAT) pathway, thus activating the transcription factors STAT1 and IRF5 that primarily transcribe M1-related genes. Acting as autocrine/paracrine effect, these can partially substitute for IFN-g in inducing and sensitizing the M1 cells. M1 activation is further characterized by production of high levels of IL-12 that supports pro-inflammatory cytokines (TNF-a, IL-1b, IL-6, and IL-23) and inflammatory chemokines (CCL2, CCL3, CCL4, IL-8, CXCL9, CXCL10, and CXCL11) that recruit neutrophils, monocytes, and activated Th1 lymphocytes. Furthermore, macrophages can assume the M2 cells. M2 activation occurs when M0 or M1 is exposed to Th2 cytokine, such as interleukin-4 (IL-4). Thus, M2 activation is characterized by the suppression of pro-inflammatory cytokine production, antigen presentation ability, and the production of increased levels of IL-10 instead of IL-12.
Fig. 5
Fig. 5
a The summary of metallosis originating from arthroplasty. A schematic diagram showing the cycle of events and conditions leading to arthroplasty, metallosis, osteolysis, and revision surgery. b Treatments of arthroplasty-related metallosis. A schematic diagram showing the current treatments of metallosis and the result of no treatment
Fig. 6
Fig. 6
Biological strategies for the treatment of wear particle-induced metallosis and osteolysis. The schematic diagram outlined some possible biological approaches to preventing periprosthetic osteolysis owing to wear particles from implants. Macrophages (M2) as an attractive target for a wide variety of therapeutic interventions, as they are serve as key regulators of inflammation, immunity, tissue regeneration, and modulation of their activation states. The transition from a state of inflammation (M1) to tissue regeneration (M2) is presumed to depend on local dynamic shifts in the macrophage phenotype from the inflammatory M1 to M2 phenotypes. This functional plasticity/polarization represents a continuous polarization state rather than strict dichotomy

Similar articles

Cited by

References

    1. Scully WF, Deren ME, Bloomfield MR. Catastrophic tibial base-plate failure of a modern cementless total knee arthroplasty implant. Arthroplasty today. 2019;5(4):446–52. - PMC - PubMed
    1. Thomas WC, Prieto HA. Total hip replacement failure due to adverse local tissue reaction from both ceramic abrasive wear and trunnion corrosion. Arthroplasty today. 2019;5(4):384–8. - PMC - PubMed
    1. US-FDA-Guidelines, Biological Responses to Metal Implants. www.fda.gov, 2019.
    1. Merolli A., Bone repair biomaterials in orthopedic surgery. In Book: Bone Repair Biomaterials, Regeneration and Clinical Applications. Second Edition : Chapter 11, Woodhead Publishing Series in Biomaterials, 2019: p. 301–327.
    1. Fernandez Bances I, Paz Aparicio J, and Alvarez Vega MA, Evaluation of titanium serum levels in patients after spine instrumentation: comparison between posterolateral and 360 masculine spinal fusion surgery. Cureus, 2019. 11(8): p. e5451. - PMC - PubMed

LinkOut - more resources