Sister chromatid exchange in patients with joint prostheses

Genotoxic properties of materials used for endoprostheses: Experimental and human data

Approximately 2 million endoprostheses are implanted annually and metal ions as well as particles are released into the body from the materials which are used. This review describes the results of studies concerning genotoxic damage caused by artificial joints. DNA damage leads to various adverse long-term health effects in humans including cancer. Experiments with mammalian cells showed that metal ions and particles from orthopedic materials cause DNA damage. Induction of chromosomal aberrations (CA) was found in several in vitro experiments and in studies with rodents with metals from orthopedic materials. Human studies focused mainly on induction of CA (7 studies). Only few investigations (4) concerned sister chromatid exchanges, oxidative DNA damage (2) and micronucleus formation (1). CA are a reliable biomarker for increased cancer risks in humans) and were increased in all studies in patients with artificial joints. No firm conclusion can be drawn at present if the effects in humans are due to oxidative stress and if dissolved metal ions or release particles play a role. Our findings indicate that patients with artificial joints may have increased cancer risks due to damage of the genetic material. Future studies should be performed to identify safe materials and to study the molecular mechanisms in detail.

Biological effects of metal degradation in hip arthroplasties

Metals and metal alloys are the most used materials in orthopedic implants. The focus is on total hip arthroplasty (THA) that, though well tolerated, may be associated with local and remote adverse effects in the medium-long term. This review aims to summarize data on the biological consequences of the metal implant degradation that have been attributed predominantly to metal-on-metal (MoM) THA. Local responses to metals consist of a broad clinical spectrum ranging from small asymptomatic tissue lesions to severe destruction of bone and soft tissues, which are designated as metallosis, adverse reactions to metal debris (ARMD), aseptic lymphocytic vasculitis associated lesion (ALVAL), and pseudotumors. In addition, the dissemination of metal particles and ions throughout the body has been associated with systemic adverse effects, including organ toxicity, cancerogenesis, teratogenicity, and immunotoxicity. As proved by the multitude of studies in this field, metal degradation may increase safety issues associated with THA, especially with MoM hip systems. Data collection regarding local, systemic and long-term effects plays an essential role to better define any safety risks and to generate scientifically based recommendations.

Assessment of the genetic risks of a metallic alloy used in medical implants

The use of artificial implants provides a palliative or permanent solution for individuals who have lost some bodily function through disease, an accident or natural wear. This functional loss can be compensated for by the use of medical devices produced from special biomaterials. Titanium alloy (Ti-6Al-4V) is a well-established primary metallic biomaterial for orthopedic implants, but the toxicity of the chemical components of this alloy has become an issue of concern. In this work, we used the MTT assay and micronucleus assay to examine the cytotoxicity and genotoxicity, respectively, of an extract obtained from this alloy. The MTT assay indicated that the mitochondrial activity and cell viability of CHO-K1 cells were unaffected by exposure to the extract. However, the micronucleus assay revealed DNA damage and an increase in micronucleus frequency at all of the concentrations tested. These results show that ions released from Ti-6Al-4V alloy can cause DNA and nuclear damage and reinforce the importance of assessing the safety of metallic medical devices constructed from biomaterials.

Cancer risk is not increased after conventional hip arthroplasty

BACKGROUND AND PURPOSE

Wear debris from conventional total hip arthroplasty (THA) induces chromosomal aberrations and DNA damage, which may promote cancerogenesis. A long latent period is required for solid tumors. We therefore re-analyzed a large THA cohort for cancer.

PATIENTS AND METHODS

We updated a cohort of 24,636 patients with primary osteoarthritis and metal-on-polyethylene THA who had been entered in the Finnish Arthroplasty Register between 1980 and 1995, and linked it to the Finnish Cancer Registry for cancer risk assessment up to 2005. The mean follow-up time was 13 years. The numbers of cancer cases observed were compared with expected rates based on incidence in the general population.

RESULTS

The standardized incidence ratio (SIR) for the whole follow-up period was 0.95 (95% confidence interval (CI): 0.92-0.97). After 10 years of follow-up, the SIR was equal to that in the normal population (SIR = 0.98, 95% CI: 0.94-1.03). Incidence of lung cancer was low throughout the follow-up time and that of prostate cancer was slightly elevated. The incidence rates for all other forms of cancer did not deviate significantly from those in the normal population.

INTERPRETATION

We found no increased cancer risk in patients with conventional THA after an average of 13 years and up to 25 years of follow-up.

Does ion release differ between hip resurfacing and metal-on-metal THA?

Modern metal-on-metal hip resurfacing was introduced as a bone-preserving method of joint reconstruction for young and active patients; however, the large diameter of the bearing surfaces is of concern for potential increased metal ion release. We hypothesized there were no differences in serum concentrations of chromium, cobalt, and molybdenum between patients who had metal-on-metal hip resurfacing (Group A; average head diameter, 48 mm; median followup, 24 months) and patients who had 28-mm metal-on-metal THA (Group B; median followup, 25 months). Serum concentrations also were compared with concentrations in healthy subjects. We identified no differences in ion levels between Groups A and B. A distinction was made according to gender. Women showed a higher chromium release in Group A whereas men had a higher cobalt release in Group B. Values obtained from Group A were higher than those of the control subjects. Our data suggest metal-on-metal bearings for THA should not be rejected because of concern regarding potential increased metal ion release; however, patients with elevated ion levels, even without loosening or toxicity, could be at higher risk and should be followed up periodically.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Ion release in stable hip arthroplasties using metal-on-metal articulating surfaces: a comparison between short- and medium-term results

The use of metallic heads articulating with metallic cups could solve the problem of polyethylene (PE) wear in total hip replacement (THR) with metal-on-PE bearings. A conspicuous release of metal ions from new models of metal-on-metal bearings has been found in the short-term, but it is yet unclear whether the medium-term corrosion rate is high or, on the contrary, it becomes negligible, because of the continuous surface finishing. Our purpose was to compare the serum ion values (nanograms per milliliter) in 15 patients with metal-on-metal stable prosthesis (Group A), in the short-term (subgroup A(1); mean follow-up: 24 mo) and medium-term (subgroup A(2); mean follow-up: 52 mo), in order to determine whether the ion release decreased with time of implant. Chromium (Cr), cobalt (Co), molybdenum (Mo) and aluminum (Al) were analyzed. Twenty-two presurgical patients were used for comparison (Group B). The reference range was obtained from a population of 27 healthy subjects (Group C). Co and Cr levels in the medium-term (subgroup A(2)) were not decreased in comparison with the short-term values (subgroup A(1)) and were significantly higher (p < 0.001) than presurgical and reference values. Otherwise, Mo and Al concentrations were not significantly increased in comparison with reference values. In conclusion, despite the apparent advantage of metal-on-metal coupling, especially in younger patient populations, there is a major concern about the extent and duration of the relevant "internal" exposure to Cr and Co ions. This exposure should be carefully monitored, in order to clarify the biologic effects of ion dissemination and, consequently, to identify risks concerning long-term toxicity of metals.

Vanadate induces DNA strand breaks in cultured human fibroblasts at doses relevant to occupational exposure

To study possible genotoxic effects of occupational exposure to vanadium pentoxide, we determined DNA strand breaks (with alkaline comet assay), 8-hydroxy-2'deoxyguanosine (8-OHdG) and the frequency of sister chromatid exchange (SCE) in whole blood leukocytes or lymphocytes of 49 male workers employed in a vanadium factory in comparison to 12 non-exposed controls. In addition, vanadate has been tested in vitro to induce DNA strand breaks in whole blood cells, isolated lymphocytes and cultured human fibroblasts of healthy donors at concentrations comparable to the observed levels of vanadium in vivo. To investigate the impact of vanadate on the repair of damaged DNA, co-exposure to UV or bleomycin was used in fibroblasts, and DNA migration in the alkaline and neutral comet assay was determined. Although, exposed workers showed a significant vanadium uptake (serum: median 5.38microg/l, range 2.18-46.35microg/l) no increase in cytogenetic effects or oxidative DNA damage in leukocytes could be demonstrated. This was consistent with the observation that in vitro exposure of whole blood leukocytes and lymphocytes to vanadate caused no significant changes in DNA strand breaks below concentrations of 1microM (50microg/l). In contrast, vanadate clearly induced DNA fragmentation in cultured fibroblasts at relevant concentrations. Combined exposure of fibroblasts to vanadate/UV or vanadate/bleomycin resulted in non-repairable DNA double strand breaks (DSBs) as seen in the neutral comet assay. We conclude that exposure of human fibroblasts to vanadate effectively causes DNA strand breaks, and co-exposure of cells to other genotoxic agents may result in persistent DNA damage.