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Introduction: Metallosis which is traditionally associated with Metal-on-Metal (MoM) hip arthroplasty can occur with other bearing surfaces too, posing diagnostic challenges. They can be asymptomatic or present with local and systemic symptoms. This article reports a case of metallosis in a total hip replacement (THR) with metal on polyethylene (PE) articulation who presented with dislocation. It also reviews the pathology and various presentations of metallosis following hip arthroplasty. Case Report: A 35-year-old female patient presented 4 years after a left THR with recurrent dislocation. It was an uncemented prosthesis with metal on PE articulation. Serology and radiological investigations were done to evaluate for infection, implant loosening, implant malposition, etc. The femoral stem appeared to be in varus malposition. She was posted for revision surgery with a pre-operative plan to change the femoral stem and head if necessary. Intraoperative signs of local metallosis were noticed. Debridement was done along with the change of the femoral stem and bearing surface to ceramic on PE. Metallosis was also later confirmed by the histopathological report. The patient has been symptom-free during the 2-year follow-up period. Conclusion: Metallosis can occur even in non-MoM articulations and a high degree of clinical suspicion is required to detect the same preoperatively. Classical signs of metallosis can often be absent in the early disease and subtle signs of instability must be looked out for even in the absence of obvious misalignment in radiographic assessment. Metallosis when combined with malposition or malalignment can be more detrimental. If detected early before osteolysis and periarticular soft tissue damage sets in, a complete revision of all the implant components and abductor damage can be avoided. In suspected cases, a lower threshold should be adopted for sending blood and joint aspirates for cobalt-chromium levels.

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Arthroplasty of the small joints of the hand and fingers is a complex problem facing the hand surgeon. Pyrocarbon implants have been available for several decades. They were originally thought to provide better functional outcomes than silicone implants in patients, mostly due to recreation of the joint anatomy. In a recent publication, pyrocarbon proximal interphalangeal joint (PIPJ) arthroplasty was found to have a higher complication and revision rate. We present a patient with pyrocarbon metallosis of the PIPJ in a revision arthroplasty procedure. Level of Evidence: Level V (Therapeutic).

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Metallosis is a medical condition that shows local and systemic clinical symptoms due to the deposition of heavy metal debris in soft tissues and bones due to metallic prostheses. The estimated incidence of Metallosis is around 5%. Clinical presentation and imaging findings can mimic tumor likely situation, However local reactions of Metallosis shows some peculiar features on cross-sectional imaging, and here we present two such cases of Metallosis with its imaging findings.

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Hip bipolar hemiarthroplasty, a widely employed surgical intervention for managing hip fractures and degenerative hip diseases, can pose significant challenges when revisions become necessary due to complications such as implant loosening, instability, or breakage. This case report presents the intricate management of a 58-year-old male who presented with worsening left hip pain a decade after undergoing hip replacement surgery. Despite a thorough preoperative assessment ruling out infection, intraoperative complexities included the necessity for extended trochanteric osteotomy (ETO) to address a broken stem and associated metallosis. Successful revision surgery was meticulously executed, incorporating techniques for implant removal, femoral shaft augmentation, and postoperative rehabilitation. The ensuing discussion explores the multifaceted aspects of failed hemiarthroplasty, emphasizing the critical roles of surgical precision, judicious patient selection, and ongoing research endeavors aimed at refining surgical strategies to optimize patient outcomes. This case underscores the imperative of a multidisciplinary approach and the continued imperative for advancements in surgical methodologies for effectively managing revision hip arthroplasty cases, thus enhancing the quality of patient care in this intricate clinical domain.

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Although adverse local tissue reactions (ALTR) have been reported for metal-on-metal implants (MoM) requiring early revision surgery, no study has looked at the accuracy of surgical pathologists in diagnosing ALTR. This study aims to investigate the accuracy of reporting adverse local tissue reactions in tissue samples following revision surgery from metal-on-metal implants. The authors reviewed histology glass slides as well as the original pathology reports of tissue processed in revision arthroplasties in 23 cases. These samples were microscopically analyzed for tissue necrosis and cystic degeneration, the presence of metal particles, corrosion byproducts, membrane formation, histiocytic cells, lymphocytic cells, and vascular pathology. The authors' findings were then compared to their corresponding original pathology reports. The authors found consistent under-reporting of the tissue findings. Most importantly, 18 samples showed evidence of metal present compared to 2 samples on original pathology reporting. The authors found that 15 samples showed evidence of pathological membranous tissue compared to just 6 on original pathology reporting. While just 3 of the original pathology reports indicated the presence of areas of predominantly lymphocytic inflammatory cells, the authors found 13 examples of such areas. Although ALTR reactions have been described as a sequala of failed MoM, the authors' data suggest that ALTR may occur more frequently than previously described. Under-reported findings of ALTR deprive both the patient and orthopaedic surgeon of important information that can help guide further follow-up.

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Metallosis is known to occur in metal-on-metal arthroplasty and has been of concern to orthopaedic surgeons worldwide. It is a rare, late complication of total knee arthroplasty (TKA), in which metal-on-metal contact leads to metal debris deposition in the surrounding tissue. Reasons for metal-on-metal contact could range from wear of the polyethylene insert to abnormal joint biomechanics. Many components can affect the development of metallosis, with polyethylene wear being the most common cause of metallosis. This paper discusses the case of an 85-year-old man who developed metallosis, attributed to polyethylene wear, 24 years after undergoing TKA. It also highlights the different components of knee prostheses, evaluates the efficacy of different types of polyethylene, and explores whether ceramic coating can improve TKA outcomes and reduce complications such as metallosis.

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BACKGROUND: Failure due to trunnionosis with adverse local tissue reaction (ALTR) has been reported with cobalt-chrome (CoCr) heads in total hip arthroplasty (THA); however, there are limited data on the use of these heads in the revision setting. The purpose of this study was to analyze the outcomes of patients who underwent revision THA with a retained femoral component and received a CoCr femoral head on a used trunnion. METHODS: In this retrospective review, we identified all patients who underwent revision THA with a retained femoral component and received a CoCr femoral head between February 2006 and March 2014. Demographic factors, implant details, and postoperative complications, including the need for repeat revisions, were recorded. In total, 107 patients were included (mean age 67 years, 74.0% women). Of the 107 patients, 24 (22.4%) required repeat revisions. RESULTS: Patients who required repeat revision were younger than those who did not (mean age: 62.9 versus 69, P = .03). The most common indications for repeat revision were instability (8 of 24, 33.3%), ALTR (5 of 24, 20.8%), and infection (4 of 18, 16.7%). Evidence of ALTR or metallosis was identified at the time of reoperation in 10 of the 24 patients who underwent re-revision (41.7%). CONCLUSIONS: The placement of a new CoCr femoral head on a used trunnion during revision THA with a retained femoral component carries a significant risk of complication (22.4%) and should be avoided when possible.

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Background and objectives: wear and corrosion can lead to the gross failure of the Morse taper junction with the consequent fracture of the true neck of the prosthetic stem in hip arthroplasty. Materials and Methods: 58-year-old male patient, with a BMI of 38 kg/m2. Because of avascular necrosis, in 2007, a metal-on-metal total hip arthroplasty was implanted in him, with a TMZF stem and a Co-Cr head. In December 2020, he complained of acute left hip pain associated with the deterioration of his left leg and total functional impairment, preceded by the crunching of the hip. X-rays and CT scan showed a fracture of the prosthetic neck that necessitated prosthetic revision surgery. A Scanning Electron Microscope (SEM) analysis of the retrieved prosthetic components was conducted. Results: Macroscopically, the trunnion showed a typical bird beak appearance, due to a massive material loss of about half of its volume. The gross material loss apparently due to abrasion extended beyond the trunnion to the point of failure on the true neck about half a centimeter distal from the taper. SEM analysis demonstrated fatigue rupture modes, and the crack began close to the neck's surface. On the lateral surface, several scratches were found, suggesting an intense wear that could be due to abrasion. Conclusions: The analysis we conducted on the explanted THA showed a ductile rupture, began close to the upper surface of the prosthetic neck where the presence of many scratches had concentrated stresses and led to a fatigue fracture.

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BACKGROUND CONTEXT: Elevated blood metal levels have been reported in patients after spinal surgery using metallic implants. Although some studies have suggested an association between heightened blood metal concentrations and potential adverse effects, estimates of the incidence of abnormal metal levels after spinal surgery have been inconsistent. PURPOSE: The aims of this systematic review and meta-analysis were to assess: (1) mean differences in blood metal ion levels between patients undergoing spinal fusion surgery and healthy controls, (2) odds of elevated blood metal ion levels after surgery compared to presurgery levels, and (3) pooled incidence of elevated blood metal ions overall and by metal type. STUDY DESIGN: Systematic review and meta-analysis. PATIENTS SAMPLE: The patient sample included 613 patients from 11 studies who underwent spinal surgery instrumentation. OUTCOME MEASURES: Blood metal ion concentrations and the incidence of patients with elevated metal levels compared with in those the control group. METHODS: A comprehensive search was conducted in PubMed, EMBASE, Scopus, and Cochrane Library to identify studies reporting blood metal ion levels after spinal fusion surgery. Mean differences (MD), odds ratios (OR), and incidence rates were pooled using random effects models. Heterogeneity was assessed using I2 statistics, and fixed-effects models were used if no heterogeneity was detected. Detailed statistical analysis was performed using the Review Manager version 5.4 software. RESULTS: The analysis included 11 studies, with a total of 613 patients. Mean blood metal ion levels were significantly higher after spinal fusion surgery (MD 0.56, 95% CI 0.17-0.96; I2=86%). Specifically, titanium levels were significantly elevated (MD 0.81, 95% CI 0.32-1.30; I2=47%). The odds of elevated blood metal ions were higher after surgery (OR 8.17, 95% CI 3.38-19.72; I2=41%), primarily driven by chromium (OR 23.50, 95% CI 5.56-99.31; I2=30%). The incidence of elevated chromium levels was found to be 66.98% (95% CI 42.31-91.65). CONCLUSION: In conclusion, blood metal ion levels, particularly titanium and chromium, were significantly increased after spinal fusion surgery compared to presurgery levels and healthy controls. Approximately 70% of the patients exhibited elevated blood levels of chromium and titanium.

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Metallosis is a known yet rare late complication of unicompartmental and total knee arthroplasty (TKA), usually secondary to either metal-backed patellar component failure, mobile-bearing polyethylene dislocation, or catastrophic polyethylene failure and wear through. The majority of literature surrounding metallosis has been published in relation to total hip arthroplasty (THA) metal on metal bearing wear or mechanically assisted crevice corrosion.This case report describes the development of metallosis in a 77-year-old male patient with advanced (Kellgren-Lawrence Grade 4) osteoarthritis with associated valgus deformity, who underwent index TKA with a semiconstrained revision knee system due to intraoperative medial collateral ligament laxity. The taper junction between the titanium alloy stem and cobalt chromium femoral component was the source of diffuse intra-articular metallosis.

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INTRODUCTION AND IMPORTANCE: Total hip arthroplasty is one of the most performed surgical interventions in the world. Adverse local tissue reactions and pseudotumors are infrequent but dangerous eventualities, which are often related with metal-on-metal or metal-on-polyethylene implants. This study wants to highlight how adverse local tissue reactions and pseudotumors must be taken into consideration during the diagnostic process. CASE PRESENTATION: We report the case of a patient with ceramic-on-ceramic modular total hip arthroplasty with titanium neck. 12 years after surgery, he complained of pain and swelling on the hip. Diagnostic tests revealed the presence of a bulky pseudotumor. During the revision surgery biopsy samples were taken and microscopical analysis revealed the presence of fibrous tissue, fibrin hemorrhagic collections, histiocytes and chronic inflammation due to foreign body, with dark refractive material of an exogenous nature. CLINICAL DISCUSSION: The possible formation of pseudotumor and metallosis reactions in hip prostheses with metal-on-metal coupling or in couplings with polyethylene is known. Many cases of pseudotumor are reported after revision of prostheses due to the breakage of ceramic components, but we did not observe any damage or corrosion of the prosthetic elements; on the other hand, we noticed an excessive retroversion of the femoral neck. It may be possible that an accurate microscopic analysis could clarify the failure of this implant. CONCLUSION: To date ceramic-ceramic coupling remains the gold standard in terms of resistance and durability for hip arthroplasty but there is still a gap of knowledge in the field of tribology and individual immune response mechanisms.

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PURPOSE: Magnetically controlled growing rods (MCGR) should be removed or changed at most two years after their implantation in the treatment of patients with early-onset scoliosis (EOS) (Safety notice July 2021). However, in the face of patients at high risk of intraoperative complications and relying on the principle of auto-fusion of the spine, some surgeons would prefer a more wait-and-see attitude. The aim of this study was to report on patients who did not undergo final fusion at the end of the lengthening program with MCGR and to compare them with those who did. METHODS: This was a multicenter study with ten centres. We collected all graduate patients with EOS who had received MCGR between 2011 and 2022. RESULTS: A total of 66 patients had final fusion at the end of the lengthening program and 24 patients kept MCGRs in situ. The mean total follow-up time was 66 months (range, 25.3-109), and the mean follow-up time after final lengthening was 24.9 months (range, 3-67.7). Regarding the main curve and thoracic height, there was no significant difference in the percentage of correction over the whole follow-up between the two groups (p = 0.099, p = 0.176) although there was a significant difference between the end of lengthening and the last follow-up (p < 0.001). After completion of the lengthening program, 18 patients who had final fusion developed 24 of the 26 recorded complications (92.3%). CONCLUSION: Contrary to the manufacturer's published safety notice, not all patients systematically benefited from the removal of the MCGRs. Although arthrodesis significantly improved the scoliotic deformity, no significant difference was found in terms of radiographic outcome between patients who underwent spinal fusion and those who kept the MCGRs in situ.

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Femoral neck trunnion dissociations are rare complications of total hip replacements. This hardware failure is often due to underlying trunnionosis which is important to recognize. We present a case of a patient with dissociation at the femoral head-neck junction of a total hip arthroplasty (THA) with a Stryker Accolade TMZF femoral stem. There was no significant preceding trauma. The complication was visualized on radiography and confirmed during revision arthroplasty.

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Metallosis with subsequent cardiac involvement is a possible long-term complication of hip arthroplasty. We report the case of a young female referred to our centre for the suspicion of cardiac amyloidosis presenting with low electrocardiogram voltage, left ventricular hypertrophy, pericardial effusion, and global and longitudinal systolic impairment with apical sparing pattern. Her medical history was remarkable for arthroplasty in the context of congenital hip dysplasia. Two years prior to presentation, she underwent revision surgery for prosthesis malfunction, and tissue metallosis was initially documented. At the current presentation, cobalt metallosis was confirmed, as the circulating cobalt and chromium levels were severely elevated. The accurate diagnosis prompted the removal of the cobalt source with extensive tissue debridement and the use of chelating agents. Reversal of the cardiac abnormalities occurred as the circulating cobalt levels returned to normal.

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Metallosis is an unusual but consequential complication arising from orthopedic hardware implantation, characterized by the deposition of metallic particles in the periprosthetic soft tissues. The incidence of metallosis associated with shoulder arthroplasties is exceptionally rare since the shoulder is not a weight-bearing joint, making it less susceptible to mechanical wear and, consequently, to conditions like particle disease and metallosis. Nevertheless, anomalous metal-on-metal interactions can develop in total shoulder arthroplasties if the polyethylene component fails due to wear, fracture, or dissociation. If left unaddressed, metallosis can incite an adverse immune-mediated local tissue response, culminating in joint destruction and adjacent soft tissues and muscle necrosis. In this case report, the diagnosis of metallosis was made in a patient with an anatomic total shoulder arthroplasty using a state-of-the-art photon counting detector CT supplemented by post-processing metal artifact reduction algorithms. This advanced imaging approach was effective in discerning the source of implant failure and in identifying manifestations of severe metallosis including osteolysis and pseudotumor formation. Advanced imaging methods can accurately characterize the severity and extent of metallosis, thereby helping guide surgical planning to mitigate serious complications associated with this condition.

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BACKGROUND: Metal-on-metal (M-M) total hip arthroplasty (THA) has shown adverse reactions to metal debris, abnormal soft-tissue reactions, and high blood metal ion levels. This study aims to: (1) assess whether the toxicity of high levels of ions is related to altered oxidative stress and (2) evaluate tribological factors related to increased blood levels of chromium (Cr) and cobalt (Co) ions. METHODS: A cross-sectional analytical descriptive study was conducted on 75 patients. A total of 25 underwent M-M THA, 25 ceramic-on-metal (C-M) THA, and 25 were on the THA waiting list. Ion metallic levels in blood, oxidative stress, physical activity, and implant position were compared. RESULTS: In the M-M group, Co and Cr levels were significantly higher than those found in the C-M group and the control group (p < 0.01). We found no differences in terms of oxidative stress between the groups. Also, we did not find a correlation between metal blood levels and oxidative stress indicators, the physical activity of the patients or the position of the implants between groups. CONCLUSIONS: The use of M-M bearing surfaces in THA raises the levels of metals in the blood without modifying oxidative stress regardless of the physical activity levels of the patients. Therefore, although patients with M-M bearings require close monitoring, it does not seem necessary to recommend the restriction of physical activity in patients with M-M or C-M arthroplasties.

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Arthroplasty-related pseudotumors are nonneoplastic and noninfectious inflammatory masses that are typically associated with adverse reaction to metal debris. Pseudotumors most commonly occur in the setting of metal-on-metal joint replacements at the hip. However, the presentation of pseudotumor at the shoulder is exceedingly rare. In this article, we reported a case of arthroplasty-related pseudotumor of the scapula. Clinical history, radiologic signs, and tissue analysis are described. Knowledge of this rare diagnosis will support clinical decision making for teams of radiologists, pathologists, oncologists, and orthopaedic surgeons who provide care for patients presenting with suspicious shoulder masses.

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While adverse local tissue reactions are well described in the total hip arthroplasty literature, there have only been case reports and case series in the total knee arthroplasty literature. There have been no cases described in the setting of a distal femoral replacement. In this case, we describe a 69-year-old female with a complex history of left knee revision arthroplasty with a distal femoral and proximal tibial replacement who presented with left knee pain and was found to have extensive adverse local tissue reaction with corrosion at the femoral stem-extension piece junction and the extension piece-distal femoral component junction. The femoral taper was then manually cleaned and modular components replaced. Corrosion at the stem-distal femoral component junction can result in adverse local tissue reaction in patients with distal femoral replacements. It is important to consider this diagnosis when evaluating patients with knee pain following distal femoral replacement.

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Introduction: Oxidized Zirconium (OXINIUM™) is a metal alloy with a ceramic surface, utilized to increase the longevity of knee and hip implantations and reduce polyethylene wear. Polyethylene-based spacers are effective in infection control and prosthetic stability. Therefore, understanding the interactions between the polyethylene spacer and metallic counterparts is essential in surgical decision-making. Furthermore, understanding how patients may present when catastrophic failure of these components arises is imperative. Herein, we present a unique case of atraumatic OXINIUM™ wear in a middle-aged female after uneventful primary total knee arthroplasty (TKA), highlighting atypical clinical features and addressing the surgical management of this unexpected implant failure. Case Report: A 51-year-old African American female presented from an outside facility with persistent left knee pain after undergoing a TKA with a Smith and Nephew OXINIUM™ coated knee. The patient presented to the senior author's clinic with worsening symptoms 2-year postoperatively from her primary left TKA by another surgeon. After a thorough work-up which was essentially unremarkable-3 years from her initial surgery - the recommendation was made for surgical revision given clinical concern for instability. During the initial surgical approach, significant sparking of the tissue was noted on the use of electrocautery. Once the capsule was dissected, black synovial fluid with soft tissue involvement was noted. Intraoperative analysis of the polyethylene spacer revealed disintegration in the medial compartment with loss of the zirconium coating along the femoral component. There was no evidence of polyethylene spacer wear within the lateral compartment. The primary components were explanted and replaced with a nickel-free implant. Following revision, the patient reported complete resolution of her symptoms with improvement in active range of motion. Conclusion: This case illustrates a unique presentation of atraumatic prosthetic surface coating failure after an uneventful primary TKA with well-aligned post-operative radiographs. Instability in the posterior stabilized total knee caused the polyethylene liner to come out of place, causing articulation of femoral and tibial components, creating the metal debris. Patients who present with persistent symptoms-of unknown etiology - after primary TKA should be considered for enhanced screenings and early surgical intervention.

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BACKGROUND: Spinal metallosis is a rare complication following spinal instrumentation whereby an inflammatory response to the metal implants results in the development of granulomatous tissue. CASE SUMMARY: We describe the case of a 78-year-old woman who had recurrence of back pain 5 years after lumbar spine posterior decompression and instrumented fusion. Lumbar spine radiographs showed hardware loosening and magnetic resonance imaging showed adjacent segment disease. Revision surgery revealed evidence of metallosis intraoperatively. CONCLUSION: Spinal metallosis can present several years after instrumentation. Radiography and computed tomography may demonstrate hardware loosening secondary to metallosis. Blood metal concentrations associated with spinal metallosis have yet to be established. Hence, metallosis is still an intraoperative and histopathological diagnosis. The presence of metallosis after spinal instrumentation likely indicates a more complex underlying problem: Pseudarthrosis, failure to address sagittal balance, infection, and cross-threading of set screws. Hence, identifying metallosis is important, but initiating treatment promptly for symptomatic implant loosening is of greater paramount.