Blood titanium level as a biomarker of orthopaedic implant wear

Abstract

Background: Joint replacement implants are usually manufactured from cobalt-chromium or titanium alloys. After the device is implanted, wear and corrosion generate metal particles and ions, which are released into local tissue and blood. The metal debris can cause a range of adverse local and systemic effects in patients. Research problem: In the case of cobalt and chromium, a blood level exceeding 7 µg L-1 indicates potential for local toxicity, and a failing implant. It has been repeatedly suggested in the literature that measurement of titanium could also be used to assess implant function. Despite an increasing interest in this biomarker, and growing use of titanium in orthopaedics, it is unclear what blood concentrations should raise concerns. This is partly due to the technical challenges involved in the measurement of titanium in biological samples. Aim: This Review summarises blood/serum titanium levels associated with well-functioning and malfunctioning prostheses, so that the prospects of using titanium measurements to gain insights into implant performance can be evaluated. Conclusion: Due to inter-laboratory analytical differences, reliable conclusions regarding "normal" and "abnormal" titanium levels in patients with orthopaedic implants are difficult to draw. Diagnosis of symptomatic patients should be based on radiographic evidence combined with blood/serum metal levels.

Evaluation of Titanium Serum Levels in Patients After Spine Instrumentation: Comparison Between Posterolateral and 360º Spinal Fusion Surgery

“…The elevated metal ion levels observed in this study were also comparable to those of the levels in adults with metal-on-metal total hip replacements [20]. Similar to spinal fusion surgery, the initial metal ion release after arthroplasty is followed by a gradual decline until it reaches a plateau.…”

“…Metal liberation from metallic implants has been reported in the body fluids of patients carrying total hip or knee replacements, intramedullary nails, and, more recently, in patients undergoing instrumental spinal arthrodesis [2][3][11][12][14][15][19][20][21][22][23][24][25][26][27][28][29][30].…”

“…Blood and serum titanium levels are well-studied and defined in relation to total hip arthroplasty, whether primary, revision, or during follow-up, from one of the first works of Agins in 1988 to the last revision of Swiatkowska [20][21]. Jacobs et al have found that the normal value for serum titanium levels for individuals without titanium-containing implants is less than 2 µgL -1 or parts per billion (ppb) [24].…”

In Vivo Biocompatibility and Immunogenicity of Metal-Phenolic Gelation

“…38,39 The other component, titanium, is a metal commonly used in the design of implants (e.g., for dental implants and joint replacement). [40][41][42] Detection of increased tissue levels of titanium is of interest clinically to aid in the assessment of implant status and prognosis, where increased levels of titanium may indicate increased implant wear. 42 In the current study, we used mass spectroscopy to evaluate titanium levels at distal tissues to the injection site (Figure 9).…”

“…[40][41][42] Detection of increased tissue levels of titanium is of interest clinically to aid in the assessment of implant status and prognosis, where increased levels of titanium may indicate increased implant wear. 42 In the current study, we used mass spectroscopy to evaluate titanium levels at distal tissues to the injection site (Figure 9). For brain, heart, kidney and lung tissues no large differences were observed in titanium concentration for tissue samples from mice which had been subcutaneously injected with TiTannic gels compared to tissue samples from mice which had not been exposed to TiTannic gels.…”