Safety of Use of Tantalum in Total Hip Arthroplasty

Elevated Blood Tantalum Concentrations in Patients Following Reconstruction of Severe Acetabular Defects in Total Hip Arthroplasty Using Modular Tantalum Augments in Combination With Uncemented Tantalum Cups

BACKGROUND

The reconstruction of acetabular defects in total hip arthroplasty (THA) can be challenging. An option to treat uncontained acetabular defects is to use modular tantalum augments in combination with cementless press-fit cups. However, modularity is associated with an increased risk of debonding and mechanical failure. In addition, metal wear particles can be released due to micromotions at the implant interface. Clinical data on the long-term results of this treatment strategy is limited. The purposes of this study were: (1) to evaluate the clinical and radiological outcome of complex THA using modular trabecular metal augments and uncemented revision cups; (2) to investigate the blood tantalum concentrations in these patients at mid-term (mean 4.5 year) follow-up; and (3) to report complications and mechanisms of failure related to this procedure.

METHODS

In this single-center study, we retrospectively reviewed data from a consecutive cohort of 27 patients who underwent complex acetabular defect reconstruction using a modular tantalum acetabular augment in combination with an uncemented tantalum cup. We evaluated the implant survival, and the radiological and clinical outcomes after a mean follow-up of 4.5 years (standard deviation 2.1; range 2.5 to 10.6 years) using patient-reported outcome scores. Blood samples were analyzed regarding tantalum concentration and compared with a control group.

RESULTS

The cumulative survival rate at 4.5 years with the end point "revision of the acetabular component for aseptic loosening" was 94.4% (95% confidence interval [CI] 71.6 to 99.2) and 82.9% (95% CI 60.5 to 93.3) for the end point "revision for any reason." The patient-reported outcome scores improved significantly up to the latest follow-up, and radiographic data showed no signs of loosening or implant migration. Median blood tantalum concentrations were significantly higher in the study group (0.15 μg/L) compared to the control group (0.002 μg/L) (P < .001).

CONCLUSIONS

This study demonstrated acceptable clinical and radiological results of cementless revision THA using modular trabecular metal implants for the reconstruction of large acetabular defects. Tantalum concentrations were significantly higher in patients who had tantalum implants compared to the control group; however, the systemic and local effects of an increased tantalum exposure are not yet fully understood and have to be further investigated.

Reconstruction of severe acetabular defects (Paprosky type III A) in total hip arthroplasty using modular tantalum augments in combination with a cemented cup

PURPOSE

Acetabular defect reconstruction can be a complex and challenging surgical procedure, with stable long-term fixation of the implants remaining the ultimate goal. The purpose of this study was (1) to evaluate the radiological and clinical outcome of complex acetabular reconstruction surgery with the use of modular tantalum TM augments in combination with cemented revision cups; (2) to investigate blood tantalum concentrations in these patients; and (3) to report complications and mechanisms of failure related to this procedure at mid-term follow-up (mean 4.5 years).

METHODS

We retrospectively reviewed 29 patients (29 hips) with severe acetabular bone loss (Paprosky type III A) reconstructed using a modular tantalum TM augment in combination with a cemented cup. We evaluated the implant survival and the radiological and clinical outcomes after a mean follow-up of 4.5 years (SD 2.2; range 8.4 - 2.1 years) using patient reported outcome scores (PROMs). Blood samples were analysed regarding tantalum concentration and compared with a control group.

RESULTS

The cumulative survival rate at 4.5 years with the endpoint "revision of the acetabular component for any reason" was 96.2% (95% Confidence Interval 75.7-99.5). The PROMs improved significantly up to the latest follow-up, and radiographic data showed only one patient with signs of initial implant migration with a broken screw and a change of the position of the augment and the cup. Mean blood tantalum concentrations were significantly higher in the study group (0.16 µg/L) compared to the control group (0.002 µg/L) (P < 0.001).

CONCLUSIONS

This study has demonstrated good mid-term (mean 4.5 years) clinical and radiological outcomes of modular tantalum TM augments in combination with a cemented cup for the reconstruction of major acetabular defects. Mean blood tantalum concentrations were increased in patients with stable tantalum implants compared to healthy controls.

Progress in the Application of Porous Tantalum Metal in Hip Joint Surgery

Porous tantalum metal is a new orthopedic implant material made of tantalum metal that has been processed by porous treatment. This material has various advantages, including high hardness, good ductility, good biocompatibility, and strong bone integration ability. Porous tantalum metal has performed well in clinical application, demonstrating excellent medium- to long-term curative effects. The use of implant products made of porous tantalum metal, such as porous tantalum rods, porous tantalum hip prostheses, and porous tantalum augments (MAs), is gradually increasing in the clinical application of hip surgery, and these products have achieved excellent therapeutic effects in the middle and late stages of various hip diseases. In recent years, the combined application of porous tantalum metal and three-dimenional (3D) printing technology to create personalized 3D-printed porous tantalum metal has led to new development directions for the treatment of complex hip joint surgical diseases. This review presents a summary of the application of porous tantalum metal in hip surgery in recent years, including clinical treatment effects and existing problems. In addition, the prospect of progress in this field is promoted.

Cardiotoxicity concerns in total joint arthroplasty

This editorial examines the cardiotoxic effects of elevated metal concentrations in patients who received total joint arthroplasty, as detailed in the study of Brennan et al. The study findings reveal that elevated cobalt and titanium levels may affect the cardiac structure and function, providing crucial insights for clinical practice and research. This editorial suggests that the close monitoring of metal ion levels in patients undergoing arthroplasty is necessary to reduce cardiovascular risk.

Tantalum Particles Promote M2 Macrophage Polarization and Regulate Local Bone Metabolism via Macrophage-Derived Exosomes Influencing the Fates of BMSCs

In this study, the regulatory role and mechanisms of tantalum (Ta) particles in the bone tissue microenvironment are explored. Ta particle deposition occurs in both clinical samples and animal tissues following porous Ta implantation. Unlike titanium (Ti) particles promoting M1 macrophage (Mϕ) polarization, Ta particles regulating calcium signaling pathways and promoting M2 Mϕ polarization. Ta-induced M2 Mϕ enhances bone marrow-derived mesenchymal stem cells (BMSCs) proliferation, migration, and osteogenic differentiation through exosomes (Exo) by upregulating miR-378a-3p/miR-221-5p and downregulating miR-155-5p/miR-212-5p. Ta particles suppress the pro-inflammatory and bone resorption effects of Ti particles in vivo and in vitro. In a rat femoral condyle bone defect model, artificial bone loaded with Ta particles promotes endogenous Mϕ polarization toward M2 differentiation at the defect site, accelerating bone repair. In conclusion, Ta particles modulate Mϕ polarization toward M2 and influence BMSCs osteogenic capacity through Exo secreted by M2 Mϕ, providing insights for potential bone repair applications.

Porous Tantalum Acetabular Cups in Primary and Revision Total Hip Arthroplasty: What Has Been the Experience So Far?-A Systematic Literature Review

BACKGROUND

The global population, especially in the Western world, is constantly aging and the need for total hip arthroplasties has rocketed, hence there has been a notable increase in revision total hip arthroplasty cases. As time has passed, a considerable developments in science and medicine have been attained which have also resulted in the evolution of both surgical techniques and implants. Continuous improvements have allowed large bore bearings to be utilized which provide an increased range of motion, with ameliorated stability and a very low rate of wear. The trend for almost the last two decades has been the employment of porous tantalum acetabular cups. Several studies exist comparing them with other conventional methods for total hip arthroplasties, exhibiting promising short and midterm results.

METHODS

The Preferred Reporting Items for Systematic Reviews and a Meta-Analysis (PRISMA) were used to identify published studies in a comprehensive search up to February 2023, and these studies were reviewed by the authors of the article. Specific rigorous pre-determined inclusion and exclusion criteria were implemented.

RESULTS

Fifty-one studies met our inclusion criteria and were involved in the systematic review. Sixteen studies examined postoperative clinical and radiological outcomes of using a tantalum cup in primary and revision total hip arthroplasty, whilst four biomechanical studies proved the superiority of tantalum acetabular components. Five articles provided a thorough comparison between tantalum and titanium acetabular cups, while the other studies analyzed long-terms results and complication rates.

CONCLUSIONS

Porous tantalum acetabular cups appear to be a valuable option in revision total hip arthroplasty, providing clinical improvement, radiological stability, and promising long-term outcomes. However, ongoing research, longer follow-up periods, and careful consideration of patient factors are essential to further validate and refine the use of tantalum in various clinical scenarios.

Trabecular Titanium for Orthopedic Applications: Balancing Antimicrobial with Osteoconductive Properties by Varying Silver Contents

Periprosthetic joint infection (PJI) and implant loosening are the most common complications after joint replacement surgery. Due to their increased surface area, additively manufactured porous metallic implants provide optimal osseointegration but they are also highly susceptible to bacterial colonization. Antibacterial surface coatings of porous metals that do not inhibit osseointegration are therefore highly desirable. The potential of silver coatings on arthroplasty implants to inhibit PJI has been demonstrated, but the optimal silver content and release kinetics have not yet been defined. A tight control over the silver deposition coatings can help overcome bacterial infections while reducing cytotoxicity to human cells. In this regard, porous titanium sputtered with silver and titanium nitride with increasing silver contents enabled controlling the antibacterial effect against common PJI pathogens while maintaining the metabolic activity of human primary cells. Electron beam melting additively manufactured titanium alloys, coated with increasing silver contents, were physico-chemically characterized and investigated for effects against common PJI pathogens. Silver contents from 7 at % to 18 at % of silver were effective in reducing bacterial growth and biofilm formation. Staphylococcus epidermidis was more susceptible to silver ions than Staphylococcus aureus. Importantly, all silver-coated titanium scaffolds supported primary human osteoblasts proliferation, differentiation, and mineralization up to 28 days. A slight reduction of cell metabolic activity was observed at earlier time points, but no detrimental effects were found at the end of the culture period. Silver release from the silver-coated scaffolds also had no measurable effects on primary osteoblast gene expression since similar expression of genes related to osteogenesis was observed regardless the presence of silver. The investigated silver-coated porous titanium scaffolds may thus enhance osseointegration while reducing the risk of biofilm formation by the most common clinically encountered pathogens.

[Partial or full component exchange in hip revision? : The relevance of off-label use and mix & match]

Off-label use is frequently practiced in hip revision arthroplasty, as there may be indications for the application of implants for purposes outside the one the manufacturers intended (i.e. large bone and soft tissue defects, obesity). Patients may also benefit from selective application of mix & match in hip revision, when the exchange of one component only is necessary and the invasiveness of surgery can be reduced. Currently, there are no formal guidelines for these situations. Therefore, within a recent EFORT initiative, evidence- and consensus-based recommendations have been developed for the safe application of off-label use and mix & match in revision hip and knee arthroplasty.

Pseudotumor and delayed recurrent dislocation after total hip arthroplasty with a modular femoral neck: A case report

RATIONALE

Pseudotumor formation after hip arthroplasty is a rare complication that can occur not only at the head-neck junction but also at the modular neck-stem junction. Dislocation is a challenging and common complication of primary and revision total hip arthroplasty compared with other complications. Similarly, the association between pseudotumors and delayed recurrent dislocation remains unclear.

PATIENT CONCERNS

We report the case of a 73-year-old woman with pseudotumor formation after total hip arthroplasty combined with a modular femoral neck. A delayed recurrent dislocation occurred in this case. Approximately 4weeks after the first revision surgery, redislocation occurred.

DIAGNOSIS

The patient was eventually diagnosed with delayed recurrent artificial hip dislocation combined with a periprosthetic pseudotumor of the right hip.

INTERVENTIONS

During the first revision surgery, a thickened, indurated cyst measuring 8×3×8cm with a red-brown wall containing brown fluid was completely excised. A cemented stem, combined with a BIOLOX Forte ceramic head, was implanted. Approximately 4weeks after surgery, redislocation occurred, and we cemented an elevated rim liner on the acetabular component with a metal head.

OUTCOMES

At the last follow-up, 49 months after revision surgery, the patient was asymptomatic with a Harris hip score of 90. The patient had a satisfactory prognosis after treatment.

LESSONS

The application of the modular-neck stem should be cautiously performed, particularly for modular prostheses containing different alloys. Pseudotumors and insufficient soft-tissue tension both contribute to hip instability, which may eventually lead to delayed repeated dislocation. In addition, femoral offset must be considered. Cement-liner technology may be used for aging patients who are less active. This case report, focusing on pseudotumors and delayed recurrent dislocations, aimed to identify factors that may support this diagnosis, which is easy to miss. Consequently, it can provide further details on the treatment process and alert orthopedic surgeons to this infrequent but important cause of delayed recurrent dislocation.

EFORT recommendations for off-label use, mix & match and mismatch in hip and knee arthroplasty

Off-label use is frequently practiced in primary and revision arthroplasty, as there may be indications for the application of implants for purposes outside the one the manufacturers intended.

Under certain circumstances, patients may benefit from selective application of mix & match. This can refer to primary hip arthroplasty (if evidence suggests that the combination of devices from different manufacturers has superior results) and revision hip or knee arthroplasty (when the exchange of one component only is necessary and the invasiveness of surgery can be reduced).

Within the EFORT ‘Implant and Patient Safety Initiative’, evidence- and consensus-based recommendations have been developed for the safe application of off-label use and mix & match in primary as well as revision hip and knee arthroplasty.

Prior to the application of a medical device for hip or knee arthroplasty off-label and within a mix & match situation, surgeons should balance the risks and benefits to the patient, obtain informed consent, and document the decision process appropriately.

Nevertheless, it is crucial for surgeons to only combine implants that are compatible. Mismatch of components, where their sizes or connections do not fit, may have catastrophic effects and is a surgical mistake.

Surgeons must be fully aware of the features of the components that they use in off-label indications or during mix & match applications, must be appropriately trained and must audit their results.

Considering the frequent practice of off-label and mix & match as well as the potential medico-legal issues, further research is necessary to obtain more data about the appropriate indications and outcomes for those procedures.

Cite this article: EFORT Open Rev 2021;6:982-1005. DOI: 10.1302/2058-5241.6.210080

The role of silver coating for arthroplasty components

Periprosthetic joint infection (PJI) is one of the most dreaded complications after arthroplasty surgery; thus numerous approaches have been undertaken to equip metal surfaces with antibacterial properties. Due to its antimicrobial effects, silver is a promising coating for metallic surfaces, and several types of silver-coated arthroplasty implants are in clinical use today. However, silver can also exert toxic effects on eukaryotic cells both in the immediate vicinity of the coated implants and systemically. In most clinically-used implants, silver coatings are applied on bulk components that are not in direct contact with bone, such as in partial or total long bone arthroplasties used in tumour or complex revision surgery. These implants differ considerably in the coating method, total silver content, and silver release rates. Safety issues, such as the occurrence of argyria, have been a cause for concern, and the efficacy of silver coatings in terms of preventing PJI is also controversial. The application of silver coatings is uncommon on parts of implants intended for cementless fixation in host bone, but this option might be highly desirable since the modification of implant surfaces in order to improve osteoconductivity can also increase bacterial adhesion. Therefore, an optimal silver content that inhibits bacterial colonization while maintaining osteoconductivity is crucial if silver were to be applied as a coating on parts intended for bone contact. This review summarizes the different methods used to apply silver coatings to arthroplasty components, with a focus on the amount and duration of silver release from the different coatings; the available experience with silver-coated implants that are in clinical use today; and future strategies to balance the effects of silver on bacteria and eukaryotic cells, and to develop silver-coated titanium components suitable for bone ingrowth. Cite this article: Bone Joint J 2021;103-B(3):423-429.

Investigation of Cytotoxicity, Oxidative Stress, and Inflammatory Responses of Tantalum Nanoparticles in THP-1-Derived Macrophages

Tantalum (Ta) is gaining attention as a biomaterial in bone tissue engineering. Although the clinical advantage of Ta-based implants for primary and revision total joint replacement (TJA) has been well documented, few studies investigated the effect of wear products of Ta implants on peri-implant cells, and their potential contribution to aseptic implant loosening. This study is aimed at examining the cytotoxicity, oxidative stress, and proinflammatory potential of Ta and TiO₂ nanoparticles (NPs) on macrophages in vitro. NPs were characterized using scanning electron microscopy, dynamic light scattering, and energy-dispersive X-ray. To test the NP-mediated cellular response in macrophages, THP-1-derived macrophages were challenged with both NPs, and cytotoxicity was analyzed using CCK-8 and LDH assays. Flow cytometry was used to investigate particle uptake and their internalization routes. NP-mediated oxidative stress was investigated by measuring the production of reactive oxygen species, and their proinflammatory potential was determined by quantifying the production of TNFα and IL-1β in cell culture supernatants using ELISA. We found that both Ta and TiO₂ NPs were taken up through actin-dependent phagocytosis, although TiO₂ NPs did also show some involvement of macropinocytosis and clathrin-mediated endocytosis. Ta NPs caused no apparent toxicity, while TiO₂ NPs demonstrated significant cytotoxicity at a concentration of over 100μg/mL at 24 h. Ta NPs induced negligible ROS generation and proinflammatory cytokines (TNFα, IL-1β) in macrophages. In contrast, TiO₂ NPs markedly induced these effects in a dose-dependent manner. Our findings indicate that Ta NPs are inert, nontoxic, and noninflammatory. Therefore, Ta could be considered an excellent biomaterial in primary and revision joint arthroplasty implants.

Comparison of the Primary Stability of Porous Tantalum and Titanium Acetabular Revision Constructs

Adequate primary stability of the acetabular revision construct is necessary for long-term implant survival. The difference in primary stability between tantalum and titanium components is unclear. Six composite hemipelvises with an acetabular defect were implanted with a tantalum augment and cup, using cement fixation between cup and augment. Relative motion was measured at cup/bone, cup/augment and bone/augment interfaces at three load levels; the results were compared to the relative motion measured at the same interfaces of a titanium cup/augment construct of identical dimensions, also implanted into composite bone. The implants showed little relative motion at all load levels between the augment and cup. At the bone/augment and bone/cup interfaces the titanium implants showed less relative motion than tantalum at 30% load (p < 0.001), but more relative motion at 50% (p = n.s.) and 100% (p < 0001) load. The load did not have a significant effect at the augment/cup interface (p = 0.086); it did have a significant effect on relative motion of both implant materials at bone/cup and bone/augment interfaces (p < 0.001). All interfaces of both constructs displayed relative motion that should permit osseointegration. Tantalum, however, may provide a greater degree of primary stability at higher loads than titanium. The clinical implication is yet to be seen