Chromium and cobalt ion concentrations in blood and serum following various types of metal-on-metal hip arthroplasties

Figures & data

Figure 1. Flow diagram illustrating the study selection process.

Characteristics of the studies included

A	B	C	D	E	F	G	H	I	J	K
Langton 2009	– ^b	ASR, HRS; 49 (41–59)	90 (42)	55 (28–77)	26			26:26	3.6 ^a (1.5–70)	2.1 ^a (0.4–271)
		BHR, HRS; 49 (38–58)	70 (42)	51 (32–67)	47	WB	P	47:47	4.0 ^a (2.4–40)	1.4 ^a (0.6–147)
Yang 2011	–	Conserve plus, HRS; NA	25 (NA)	37 (24–46)	24	S	A	24:24	0.7 (0.4–0.8)	0.4 (0.3–0.5)
Isaac 2009	–	ASR, HRS; 53 (41–61)	77 (56)	60 (31–69)	24	WB	P	24:24	1.5 ^a (NA)	1.5 ^a (NA)
Heisel 2008	–	ASR, HRS; 48 (NA)	15 (7)	51 (31–61)	12	S	H	12:12	2.7 ^a (0.5–20)	2.5 ^a (0.4–15)
Hasegawa 2012	–	Optimom, THA, NA	75 (11)	65 (40–84)	24	S	P/A	12:12	2.1 ^a (NA)	2.3 ^a (NA)
Kim 2011	–	Conserve plus, HRS; NA	97 (76)	48 (18–65)	24	S	H	24:24	2.7 (0.5–11)	1.8 (0.5–7.1)
Lavigne 2011	–	M2a-magnum, THA; NA						24:24	1.1 ^a (0.4–14)	0.7 ^a (0.3–13)
		Metasul LDH, THA; NA						24:24	1.3 ^a (0.4–6.1)	2.7 ^a (0.4–8.3)
		ASR XL, THA; NA	144 (NA)	NA	24	WB	H	24:24	1.3 ^a (0.2–6.2)	1.3 ^a (0.3–7.6)
		BHR+ sleeve, THA; NA						24:24	1.9 ^a (0.1–21)	1.9 ^a (0.4–5.3)
Savarino 2006	–	Metasul, THA; 28 (0)	42 (23)	57 (31–79)	53	S	A	53:53	2.1 (0.1–8.6)	1.6 (0.1–7.3)
Moroni 2008	– ^b	BHR, HRS; 47 (NA)	20 (11)	53 (30–65)	58			24:24	2.3 (0.5–11)	1.1 (0.3–5.6)
		Metasul, THA; 28 (0)	35 (19)	60 (41–79)	56	S	A	24:24	2.0 (0.1–8.0)	1.4 (0.1–7.3)
Langton 2010	– ^b	ASR HRS; 49 (39–59)	418 (234)	56 (28–77)	35			35:35	4.2 ^a (1.5–70)	2.7 ^a (0.4–271)
		BHR, HRS; 48 (38–58)	155 (88)	51 (32–67)	63	WB	P	63:63	4.2 ^a (2.4–40)	1.8 ^a (0.6–147)
		ASR XL, THA; 47 (39–57)	87 (34)	67 (25–85)	41			41:41	3.7 ^a (2.4–22)	3.3 ^a (1.1–32)
Dahlstrand 2009	+	Metasul, THA; 28 (0)	28 (15)	65 (45–74)	24	S	H	12:24	1.2 (NA)	1.0 (NA)
Witzleb 2006	–	Metasul, THA; 28 (0)	60 (42)	54 (45–62)				12:24	1.6 ^a (NA)	1.7 ^a (NA)
	–	BHR, HRS; 50 (NA)	111 (44)	51 (46–58)	24	S	A	24:24	5.1 ^a (NA)	4.3 ^a (NA)
Bernstein 2011	–	Ultamet, THA; NA (40–44)	56 (48)	60 (36–74)	12	WB	P	12:12	0.5 ^a (NA)	2.2 ^a (NA)
Back 2005	–	BHR, HRS; NA (38–52)	16 (12)	51 (21–74)	24	S	P/A	12:12	1.5 (0.2–3.7)	0.7 (0.3–1.9)
Savarino 2002	–	Metasul, THA; 28 (0)	26 (12)	48 (30–67)	26	S	A	26:26	1.7 (0.2–6.7)	1.3 (0.3–5.3)
Clarke 2003	– ^b	BHR, HRS; 48 (38–54)	16 (NA)						2.6 ^a (1.5–8.6)	2.1 ^a (0.8–8.5)
		Cormet 2000, HRS; 48 (38–54)	6 (NA)	53 (39–68)	16	S	P	16	4.2 ^a (1.3–6.7)	3.0 ^a (1.2–6.9)
		Ultima, THA; 28 (0)	22 (NA)	61 (39–77)	20			20	1.0 ^a (0.1–3.0)	1.3 ^a (0.9–5.1)
Smolders 2011a	+	Conserve plus, HRS; 48 (42–54)	60 (36)	55 (25–65)				24:12	1.1 ^a (0.1–8.4)	1.4 ^a (0.6–12)
		Metasul, THA; 28 (0)	32 (20)	59 (55–75)	24	WB	P	24:24	0.6 ^a (0.1–2.1)	1.1 ^a (0.1–2.2)
Smolders 2011b	+	Conserve plus, HRS; 49 (NA)	38 (21)	58 (24–65)				24:12	1.2 ^a (0.1–10)	1.3 ^a (0.6–8.3)
		Metasul, THA; 28 (0)	33 (29)	59 (37–65)	24	WB	P	24:24	0.5 ^a (0.1–2.1)	1.0 ^a (0.1–4.2)
Antoniou 2008	–	Metasul, THA; 28 (0)	28 (11)	61 (32–74)					0.6 ^a (NA)	2.6 ^a (NA)
		Ultamet, THA; 36 (0)	58 (25)	58 (37–70)	12	WB	P	12:12	0.4 ^a (NA)	2.3 ^a (NA)
		ASR, HRS; NA	70 (54)	55 (33–73)					0.5 ^a (NA)	2.4 ^a (NA)
Vendittoli 2010	+	Metasul, THA; 28 (0)	53 (33)	51 (30–65)				24:24	1.6 (0.8–5.7)	0.9 (0.2–4.9)
		Durom, HRS; 49 (40–58)	64 (42)	49 (25–64)	24	WB	H	24:24	1.6 (0.4–3.7)	0.7 (0.2–2.9)
Vendittoli 2011	–	Metasul, THA; 48 (42–56)	29 (15)	50 (31–62)	12	WB	H	12:12	1.3 (0.6–3.1)	2.2 (0.3–5.6)
Lardanchet 2012	–	Metasul LDH, THA; NA	24 (10)	67 (50–79)	12	S	P/A	12:12	1.6 ^a (1.0–2.4)	2.8 ^a (1.3–6.6)
	–	M2a-magnum, THA; NA	23 (9)	67 (51–81)	12	S	P/A	12:12	2.5 ^a (1.9–3.8)	2.2 ^a (1.4–3.1)
	–	Conserve total, THA; NA	20 (11)	65 (45–77)	12	S	P/A	12:12	4.4 ^a (1.4–6.3)	7.5 ^a (3.6–10)
Williams 2011	–	Metasul LDH, THA; NA	31 (NA)	NA	24	S	H	24:24	2.8 ^a (0.7–50)	4.5 ^a (0.5–59)
	–	Durom, HRS, NA	20 (NA)	NA	24	S	H	24:24	1.1 ^a (0.5–143)	0.8 ^a (0.4–196)
Skipor 2002	–	Conserve plus, HRS; 48 (38–52)	25 (17)	49 (28–62)	12	S	A	12:12	1.8 (0.6–4.3)	1.1 (0.4–2.8)
Savarino 2008	– ^b	Metasul, THA; 28 (0)	16 (7)	54 (46–63)	121	S	A	121	0.9 (0.3–2.2)	0.7 (0.3–1.6)
Imanishi 2010	–	Ultamet, THA; 36 (0)	33 (4)	60 (41–83)	12	S	P	12:12	0.8 ^a (NA)	1.1 ^a (NA)
Daniel 2009	–	BHR, HRS; NA (50–54)	26 (26)	53 (35–74)	72	WB	H	12:12	2.4 (0.7–3.8)	1.3 (0.4–3.8)
Langton 2008	–	ASR, HRS; 49 ^a (41–59)	76 (49)	55 (35–74)	26	WB	P	26:26	3.4 ^a (1.5–70)	2.0 ^a (0.4–271)
Daniel 2006	–	BHR, HRS; NA (50–54)	26 (NA)	53 (19–67)	12	WB	H	12:12	2.4 (NA)	1.3 (NA)
	–	Metasul, THA; 28 (0)	28 (NA)	57 (39–63)	12	WB	H	12:12	1.7 (NA)	1.7 (NA)
Garbuz 2010	+	Durom, HRS; NA (50–54)	48 (43)	52 (NA)	13	S	H	24:24	0.8 (NA)	0.5 (NA)
Pattyn 2011	+	BHR, HRS; NA	20 (12)	49 (NA)	24	WB	P	12:24	1.5 (0.5–2.7)	2.1 (0.5–6.5)
	+	Durom, HRS; NA	22 (18)	53 (NA)	24	WB	P	12:24	1.0 (0.5–6.4)	1.1 (0.5–3.3)
	+	Metasul, THA; 28 (0)	10 (4)	54 (NA)	24	WB	P	12:24	1.8 (0.5–4.8)	2.0 (0.7–5.2)
Lhotka 2003	–	Sikomet-SM21, THA; 28 (0)	128 (41)	57 (NA)	42–48	WB	A	45:45	1.8 (NA)	3.4 (NA)
Allan 2007	–	Comet 2000, HRS; 47 (40–56)	35 (20)	51 (33–66)	28	S	H	12:12	5.1 (NA)	4.3 (NA)
Iavicoli 2006	–	Conserve plus, HRS; 44 (38–50)	14 (6)	66 (44–84)	15	S	P	45:14	2.9 (0.5–5.0)	14 (3.7–43)
Beaulé 2011	–	Conserve plus, HRS; 48 (NA)	26 (21)	54 (NA)	24	S	H	24:24	3.1 (0.6–11)	2.0 (0.4–7.1)
	–	A-Class BFH, THA; 48 (NA)	26 (18)	60 (NA)	24	S	H	12:12	3.0 (0.9–6.7)	5.1 (0.8–13)
Daniel 2007	–	BHR, HRS; NA (50–54)	26 (NA)	53 (29–67)	48	WB	H	12:12	2.4 (0.7–3.8)	1.3 (0.4–3.8)
Mauer-Erti 2012	–	ASR, HRS; 49 (45–51)	8 (5)	47 (33–57)	24	S	A	12:12	2.1 ^a (0.8–9.7)	1.4 ^a (0–3.9)
	–	ASR XL, THA; 46 (41–51)	28 (15)	52 (40–61)	24	S	A	24:24	4.6 ^a (0.7–52)	3.6 ^a (0.3–78)
Milovsev 2005	– ^b	Sikomet-SM21, THA; 28 (0)	25 (11)	57 (36–72)	60	S	A	60:60	1.3 (0.3–6.5)	0.3 (0.1–0.9)
Desy 2011	– ^b	ASR, HRS; 53 (46–59)	91 (74)	53 (38–73)	37	WB	P	37:37	0.7 ^a (NA)	2.1 ^a (NA)
Daniel 2008	–	Metasul, THA; 28 (0)	20 (NA)	63 (55–75)	12	WB	H	12:12	1.7 (NA)	1.7 (NA)
	–	BHR+ sleeve, THA; NA (42–	28 (NA)	61 (37–77)	12	WB	H	12:12	1.4 (NA)	2.3 (NA)
Clarke 2003	–	Ultima, THA; 28 (NA)	22 (NA)	61 (39–77)	20	S	P	20:20	1.0 ^a (0.1–3.2)	1.3 ^a (0.9–5.1)
Lazennec 2009	–	Metasul, THA; 28 (0)	109 (56)	54 (30–60)	108	S	O	36:36	2.1 ^a (1.0–3.0)	1.7 ^a (1.0–2.5)
Holland 2012	–	BHR, HRS; 50 ^a (42–58)	90 (74)	51 (21–68)	115	WB	P	115:115	1.7 ^a (0.4–15)	1.7 ^a (0.5–20)

^a Median values (else mean values)

A First author and year of publication

B Randomized clinical trial

^b retrospective study

C Hip prosthesis type; size (range) of femoral component, mm

D Number of participants (male number)

E Age (range)

F Follow-up time, months

G Sample: WB – whole bloode, S – serum

H Method of analysis

A – atomic absorption spectrometry

H – high-resolution inductively coupled mass spectrophotometry

O – inductively coupled optical emission spectrometry

P – inductively coupled plasma mass spectrophotometry

I Time (months) to peak ion concentration, Cr:Co

J Cr level (range), µg/L

K Co level (range), µg/L

Figure 2. Average Cr concentration and range, calculated from medians, in blood (red) and serum (blue) following various types of MoM hip arthroplasties.

Figure 3. Average Co concentration and range, calculated from medians, in blood (red) and serum (blue) following various types of MoM hip arthroplasties.

Figure 4. Average Cr concentration and range, calculated from means, in blood (red) and serum (blue) following various types of MoM hip arthroplasties.

Figure 5. Average Co concentration and range, calculated from means, in blood (red) and serum (blue) following various types of MoM hip arthroplasties.*upper range 10.1 μg/L.

Langton DJ, Jameson SS, Joyce TJ, Webb J, Nargol AV. The effect of component size and orientation on the concentrations of metal ions after resurfacing arthroplasty of the hip. J Bone Joint Surg (Br) 2008; 90 (9): 1143-51.

 PubMed Web of Science ®Google Scholar

Yang J, Shen B, Zhou Z, Pei F, Kang P. Changes in cobalt and chromium levels after metal-on-metal hip resurfacing in young, active Chinese patients. J Arthroplasty 2011; 26 (1): 65-70.

 PubMedGoogle Scholar

Isaac GH, Siebel T, Oakeshott RD, McLennan-Smith R, Cobb AG, Schmalzried TP, Vail TP. Changes in whole blood metal ion levels following resurfacing: serial measurements in a multi-centre study. Hip Int 2009; 19 (4): 330-7.

 PubMedGoogle Scholar

Heisel C, Streich N, Krachler M, Jakubowitz E, Kretzer JP. Characterization of the running-in period in total hip resurfacing arthroplasty: an in vivo and in vitro metal ion analysis. J Bone Joint Surg (Am) (Suppl 3) 2008; 90: 125-33.

 PubMed Web of Science ®Google Scholar

Hasegawa M, Yoshida K, Wakabayashi H, Sudo A. Cobalt and chromium Ion release after large-diameter metal-on-metal total hip arthroplasty. J Arthroplasty 2012; 27 (6): 990-6.

 PubMedGoogle Scholar

Kim PR, Beaule PE, Dunbar M, Lee JK, Birkett N, Turner MC, Yenugadhati N, Armstrong V, Krewski D. Cobalt and chromium levels in blood and urine following hip resurfacing arthroplasty with the Conserve Plus implant. J Bone Joint Surg (Am) (Suppl 2) 2011; 93: 107-17.

 PubMedGoogle Scholar

Lavigne M, Belzile EL, Roy A, Morin F, Amzica T, Vendittoli PA. Comparison of whole-blood metal ion levels in four types of metal-on-metal large-diameter femoral head total hip arthroplasty: the potential influence of the adapter sleeve. J Bone Joint Surg (Am) (Suppl 2) 2011; 93: 128-36.

 PubMed Web of Science ®Google Scholar

Savarino L, Greco M, Cenni E, Cavasinni L, Rotini R, Baldini N, Giunti A. Differences in ion release after ceramic-on-ceramic and metal-on-metal total hip replacement. Medium-term follow-up. J Bone Joint Surg (Br) 2006; 88 (4): 472-6.

 PubMedGoogle Scholar

Moroni A, Savarino L, Cadossi M, Baldini N, Giannini S. Does ion release differ between hip resurfacing and metal-on-metal THA? Clin Orthop 2008; 466 (3): 700-l7.

 Google Scholar

Langton DJ, Sprowson AP, Joyce TJ, Reed M, Carluke I, Partington P, Nargol AV. Blood metal ion concentrations after hip resurfacing arthroplasty: a comparative study of articular surface replacement and Birmingham Hip Resurfacing arthroplasties. J Bone Joint Surg (Br) 2009; 91 (10): 1287-95.

 PubMed Web of Science ®Google Scholar

Dahlstrand H, Stark A, Anissian L, Hailer NP. Elevated serum concentrations of cobalt, chromium, nickel, and manganese after metal-on-metal alloarthroplasty of the hip: a prospective randomized study. J Arthroplasty 2009; 24 (6): 837-45.

 PubMed Web of Science ®Google Scholar

Witzleb WC, Ziegler J, Krummenauer F, Neumeister V, Guenther KP. Exposure to chromium, cobalt and molybdenum from metal-on-metal total hip replacement and hip resurfacing arthroplasty. Acta Orthop 2006; 77 (5): 697-705.

 PubMed Web of Science ®Google Scholar

Bernstein M, Walsh A, Petit A, Zukor DJ, Huk OL, Antoniou J. Femoral head size does not affect ion values in metal-on-metal total hips. Clin Orthop 2011; 469 (6): 1642-50.

 PubMed Web of Science ®Google Scholar

Back DL, Young DA, Shimmin AJ. How do serum cobalt and chromium levels change after metal-on-metal hip resurfacing? Clin Orthop 2005; (438): 177-81.

 PubMedGoogle Scholar

Savarino L, Granchi D, Ciapetti G, Cenni E, Nardi PA, Rotini R, Veronesi CA, Baldini N, Giunti A. Ion release in patients with metal-on-metal hip bearings in total joint replacement: a comparison with metal-on-polyethylene bearings. J Biomed Mater Res 2002; 63 (5): 467-74.

 PubMedGoogle Scholar

Clarke MT, Lee PT, Arora A, Villar RN. Levels of metal ions after small- and large-diameter metal-on-metal hip arthroplasty. J Bone Joint Surg (Br) 2003; 85 (6): 913-7.

 Google Scholar

Smolders JM, Bisseling P, Hol A, Van Der Straeten C, Schreurs BW, van Susante JL. Metal ion interpretation in resurfacing versus conventional hip arthroplasty and in whole blood versus serum. How should we interpret metal ion data. Hip Int 2011a; 21 (5): 587-95.

 PubMedGoogle Scholar

Smolders JM, Hol A, Rijnberg WJ, van Susante JL. Metal ion levels and functional results after either resurfacing hip arthroplasty or conventional metal-on-metal hip arthroplasty. Acta Orthop 2011b; 82 (5): 559-66.

 PubMedGoogle Scholar

Antoniou J, Zukor DJ, Mwale F, Minarik W, Petit A, Huk OL. Metal ion levels in the blood of patients after hip resurfacing: a comparison between twenty-eight and thirty-six-millimeter-head metal-on-metal prostheses. J Bone Joint Surg (Am) (Suppl 3) 2008; 90: 142-8.

 PubMed Web of Science ®Google Scholar

Vendittoli PA, Roy A, Mottard S, Girard J, Lusignan D, Lavigne M. Metal ion release from bearing wear and corrosion with 28 mm and large-diameter metal-on-metal bearing articulations: a follow-up study. J Bone Joint Surg (Br) 2010; 92 (1): 12-9.

 PubMedGoogle Scholar

Vendittoli PA, Amzica T, Roy AG, Lusignan D, Girard J, Lavigne M. Metal Ion release with large-diameter metal-on-metal hip arthroplasty. J Arthroplasty 2011; 26 (2): 282-8.

 PubMed Web of Science ®Google Scholar

Lardanchet JF, Taviaux J, Arnalsteen D, Gabrion A, Mertl P. One-year prospective comparative study of three large-diameter metal-on-metal total hip prostheses: serum metal ion levels and clinical outcomes. Orthop Traumatol Surg Res 2012; 98 (3): 265-74.

 PubMed Web of Science ®Google Scholar

Williams DH, Greidanus NV, Masri BA, Duncan CP, Garbuz DS. Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg (Am) 2011; 93 (23): 2164-71.

 PubMed Web of Science ®Google Scholar

Skipor AK, Campbell PA, Patterson LM, Anstutz HC, Schmalzried TP, Jacobs JJ. Serum and urine metal levels in patients with metal-on-metal surface arthroplasty. J Mater Sci Mater Med 2002; 13 (12): 1227-34.

 PubMedGoogle Scholar

Savarino L, Padovani G, Ferretti M, Greco M, Cenni E, Perrone G, Greco F, Baldini N, Giunti A. Serum ion levels after ceramic-on-ceramic and metal-on-metal total hip arthroplasty: 8-year minimum follow-up. J Orthop Res 2008; 26 (12): 1569-76.

 PubMed Web of Science ®Google Scholar

Imanishi T, Hasegawa M, Sudo A. Serum metal ion levels after second-generation metal-on-metal total hip arthroplasty. Arch Orthop Trauma Surg 2010; 130 (12): 1447-50.

 PubMedGoogle Scholar

Daniel J, Ziaee H, Pradhan C, Pynsent PB, McMinn DJ. Blood and urine metal ion levels in young and active patients after Birmingham hip resurfacing arthroplasty: four-year results of a prospective longitudinal study. J Bone Joint Surg (Br) 2007a; 89 (2): 169-73.

 PubMedGoogle Scholar

Daniel J, Ziaee H, Salama A, Pradhan C, McMinn DJ. The effect of the diameter of metal-on-metal bearings on systemic exposure to cobalt and chromium. J Bone Joint Surg (Br) 2006; 88 (4): 443-8.

 PubMedGoogle Scholar

Garbuz DS, Tanzer M, Greidanus NV, Masri BA, Duncan CP. The John Charnley Award: Metal-on-metal hip resurfacing versus large-diameter head metal-on-metal total hip arthroplasty: a randomized clinical trial. Clin Orthop 2010; 468 (2): 318-25.

 PubMed Web of Science ®Google Scholar

Pattyn CA, Lauwagie SN, Verdonk RC. Whole blood metal ion concentrations in correlation with activity level in three different metal-on-metal bearings. J Arthroplasty 2011; 26 (1): 58-64.

 PubMedGoogle Scholar

Lhotka C, Szekeres T, Steffan I, Zhuber K, Zweymuller K. Four-year study of cobalt and chromium blood levels in patients managed with two different metal-on-metal total hip replacements. J Orthop Res 2003; 21 (2): 189-95.

 PubMed Web of Science ®Google Scholar

Allan DG, Trammell R, Dyrstad B, Barnhart B, Milbrandt JC. Serum cobalt and chromium elevations following hip resurfacing with the Cormet 2000 device. J Surg Orthop Adv 2007; 16 (1): 12-8.

 PubMedGoogle Scholar

Iavicoli I, Falcone G, Alessandrelli M, Cresti R, De S, V, Salvatori S, Alimonti A, Carelli G. The release of metals from metal-on-metal surface arthroplasty of the hip. J Trace Elem Med Biol 2006; 20 (1): 25-31.

 PubMedGoogle Scholar

Maurer-Ertl W, Friesenbichler J, Sadoghi P, Pechmann M, Trennheuser M, Leithner A. Metal ion levels in large-diameter total hip and resurfacing hip arthroplasty - Preliminary results of a prospective five year study after two years of follow-up. BMC Musculoskelet Disord 2012; 13 (1): 56.

 PubMedGoogle Scholar

Milosev I, Pisot V, Campbell P. Serum levels of cobalt and chromium in patients with Sikomet metal-metal total hip replacements. J Orthop Res 2005; 23 (3): 526-35.

 PubMed Web of Science ®Google Scholar

Desy NM, Bergeron SG, Petit A, Huk OL, Antoniou J. Surgical variables influence metal ion levels after hip resurfacing. Clin Orthop 2011; 469 (6): 1635-41.

 PubMedGoogle Scholar

Daniel J, Ziaee H, Pradhan C, McMinn DJ. Systemic metal exposure in large- and small-diameter metal-on-metal total hip replacements. Orthopedics (Suppl 2) 2008; 31 (12).

 Google Scholar

Lazennec JY, Boyer P, Poupon J, Rousseau MA, Roy C, Ravaud P, Catonne Y. Outcome and serum ion determination up to 11 years after implantation of a cemented metal-on-metal hip prosthesis. Acta Orthop 2009; 80 (2): 168-73.

 PubMed Web of Science ®Google Scholar

Holland JP, Langton DJ, Hashmi M. Ten-year clinical, radiological and metal ion analysis of the Birmingham Hip Resurfacing: from a single, non-designer surgeon. J Bone Joint Surg (Br) 2012; 94 (4): 471-6.

 PubMedGoogle Scholar