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Metallosis Identified via Intraoperative Cell Salvage: A Case Report

Parker, Lauren M. MD*; Yazer, Mark H. MD†‡; Waters, Jonathan H. MD§‖

doi: 10.1213/XAA.0000000000000428
Case Reports: Case Report
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Intraoperative cell salvage, whereby shed surgical blood is recovered for autologous reinfusion, is frequently used during hip arthroplasty because of the potential for significant blood loss. The following cases describe 2 instances in which chromium and cobalt particles from patients’ metal-on-metal hip implants were identified within the blood recovery system. Results of heavy metal testing during the second case suggest that the use of a leukocyte reduction filter effectively reduces metal concentrations to below normal circulating levels. However, the reinfusion of cell salvage blood containing obvious metallic particles cannot be recommended until the effectiveness of leukocyte reduction filters in removing heavy metals has been further tested.

From the *University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania; §Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and The McGowan Institute for Regenerative Medicine, Pittsburgh, Pennsylvania.

Accepted for publication August 9, 2016.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Lauren M. Parker, MD, Department of Anesthesiology, University of Pittsburgh Medical Center, 3471 Fifth Ave, Suite 910, Pittsburgh, PA 15213. Address e-mail to arkerlm2@upmc.edu.

Intraoperative cell salvage, whereby shed surgical blood is recovered for the purpose of autologous transfusion, has a number of both relative and absolute contraindications. Examples of relative contraindications to its use include oncologic surgery and certain hematologic disorders such as sickle cell disease. The use of certain procoagulants such as thrombin has been deemed as an absolute contraindication, because of the potential for thrombotic events after the reinfusion.1 The following cases describe 2 instances in which chromium and cobalt from patients’ metal-on-metal hip implants were identified within the blood recovery system during surgery. The primary question that arises from these cases is whether this form of contamination presents a safety concern regarding the use of cell salvage during joint arthroplasty.

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WRITTEN CONSENT STATEMENT

The authors of this case report hereby state that the involved patients provided written permission for the report to be published.

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CASE DESCRIPTIONS

Case 1

An 81-year-old man with a medical history significant for osteoarthritis resulting in bilateral total hip arthroplasties and subsequent revision of the right hip presented to our facility in November 2013 for revision of the left hip (initial implant: Stryker Orthopedics Accolade femoral component [Stryker Orthopedics, Kalamazoo, MI], Zimmer Orthopedics acetabular component [Zimmer Orthopedics, Warsaw, IN]). The patient had been relatively active and without pain until approximately 1 month before the presentation, at which time he felt a “pop” followed by progressive hip pain. Plain radiographs at the time of presentation demonstrated significant corrosion at the femoral head–neck taper junction as compared with the previous x-rays performed 1 year before. Figure 1 depicts the corroded metal hip implant as it was recovered from the patient during surgery.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Revision of the left hip was performed under spinal anesthesia and a low-dose propofol infusion without surgical or anesthetic complications. Despite an initial hemoglobin of 14.3 g/dL, intraoperative cell salvage (BRAT 2 Autologous Transfusion System, Sorin Group) was used because of the potential for significant blood loss and the need for transfusion. Blood was suctioned from the operative field at a constant pressure of 150 mm Hg. During the procedure, black particulate matter was identified both within the collection reservoir of the blood recovery system (Figure 2) and swirling throughout the processed blood. Only 200 mL of blood was recovered during the operation, and it is unlikely that such a small volume would have been reinfused even in the absence of visible contaminants. However, it is likely that the heavy metal contamination would have precluded transfusion even if there had been more significant surgical blood loss. A sample of blood that had undergone standard washing (135 mL bowl, 1000 mL wash, automated setting) and filtration (removal of particles exceeding 120 μm in diameter) by the blood recovery system was subsequently tested for chromium and cobalt using inductively coupled plasma mass spectrometry. The plasma concentration of chromium in this sample of the salvaged blood was 58 μg/L (upper limit of normal 2 μg/L) and that of cobalt was 3 μg/L (upper limit of normal 2 μg/L).

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Case 2

A 72-year-old woman with a medical history significant for osteoarthritis presented in May 2015 for the revision of a right hip replacement (initial implant: Stryker Orthopedics Accolade femoral component, Zimmer Orthopedics acetabular component). The patient had done well after her initial surgery, until she sustained a fall that resulted in persistent buttock pain. Plain radiographs confirmed instability of the right femoral head. As per the recommendation of her surgeon, who had suspected joint metallosis, the patient also underwent heavy metal testing preoperatively. The serum chromium concentration was within normal limits at 1.4 μg/L; however, the serum cobalt concentration was markedly elevated at 6.1 μg/L.

Revision of the right hip was performed under spinal anesthesia and a low-dose propofol infusion without surgical or anesthetic complications. Intraoperative cell salvage (BRAT 2 Autologous Transfusion System, Sorin Group) was used in anticipation of significant blood loss despite a starting hemoglobin of 12.7 g/dL. Only 130 mL of blood was recovered during the operation, obviating any need for transfusion. It is again reasonable to assume that a larger volume of blood might have been held because of concerns about heavy metal contamination.

Table.

Table.

In contrast with the previous case, in which a single sample of blood was collected following the standard wash and filtration process as described, 3 separate blood samples were collected at different stages of the recovery process from the second patient. The first blood sample was taken from the cell salvage collection reservoir, the second from the postwash primary reinfusion bag, and the third from the postfiltration secondary reinfusion bag. Each blood sample underwent the same heavy metal testing via inductively coupled plasma mass spectrometry. The Table illustrates that although both serum chromium and cobalt concentrations were reduced somewhat by washing (from 520 μg/L and 79 μg/L to 210 μg/L and 39 μ/L, respectively), only after filtration were they reduced to below normal circulating levels. A second major difference between the 2 cases was the use of different filtration devices. In the first case, a standard filter that removes particles exceeding 120 μm in diameter was used, whereas in the second case, a leukocyte reduction filter (LeukoGuard RS Leukocyte Reduction Filter, PALL Medical, Port Washington, NY) that is capable of removing particles as small as 40 μm in diameter was used.

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DISCUSSION

Each year, more than 300,000 total hip replacements are performed in the United States. The hip prosthesis consists of a femoral head component, an acetabular component, and a bearing surface composed of metal, polyethylene, ceramic, or a combination of these materials.2 Several recent studies have questioned the safety and efficacy of metal-on-metal hip prostheses, in which chromium and cobalt are the primary constituents. Metal-on-metal prostheses frequently undergo corrosion over time, particularly at the head–neck taper junction. Deterioration of the joint leads to the release of chromium and cobalt ions into the synovial joint space, periprosthetic tissue, and bloodstream.3 The presence of metal debris surrounding the joint triggers local inflammatory reactions that often manifest as pain, spontaneous joint dislocation, and nerve palsy.2 Widespread soft tissue and bone involvement may lead to implant failure requiring surgical revision. Marked elevations in serum chromium and/or cobalt levels are also not uncommon. At sufficiently high concentrations, there is the potential for systemic metal toxicity. Cobalt toxicity, most commonly associated with either chronic ingestion of cobalt salts or breakdown of metal prostheses, manifests as neurotoxicity (hearing loss, visual impairment, polyneuropathy), dilated cardiomyopathy, hypothyroidism, or polycythemia.4 Symptoms of chromium toxicity are most commonly because of inhalational or skin exposure and primarily affect the lungs and skin. The gastrointestinal tract, liver, and kidneys are other target organs for chromium toxicity.5

A frequent complication associated with the total hip arthroplasty is significant blood loss. Intraoperative cell salvage is frequently used during these surgeries so that shed blood may be recovered and, if necessary, transfused to patients. Ultimately, this can reduce the need for allogeneic blood transfusion. Several studies have demonstrated the ability of blood recovery systems to reduce serum metal concentrations; however, the levels were still elevated above normal circulating levels.6,7 The second case presented here is the first instance in which previously elevated chromium and cobalt concentrations were reduced via cell salvage and the use of a leukocyte filter to levels below the upper limits of normal. It is reasonable to assume that the leukocyte reduction filter capable of microaggregate removal was responsible for this reduction. Although these findings suggest that filtration reduces the levels of heavy metals, the reinfusion of cell salvage blood containing obvious metallic particles cannot be recommended until the effectiveness of leukocyte reduction filters in removing heavy metals has been further tested.

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DISCLOSURES

Name: Lauren M. Parker, MD.

Contribution: This author helped complete the manuscript.

Name: Mark H. Yazer, MD.

Contribution: This author helped complete the manuscript.

Name: Jonathan H. Waters, MD.

Contribution: This author helped complete the manuscript.

This manuscript was handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.

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REFERENCES

1. Esper SA, Waters JH. Intra-operative cell salvage: a fresh look at the indications and contraindications. Blood Transfus. 2011;9:139147.
2. Campbell JR, Estey MP. Metal release from hip prostheses: cobalt and chromium toxicity and the role of the clinical laboratory. Clin Chem Lab Med. 2013;51:213220.
3. Pivec R, Meneghini RM, Hozack WJ, Westrich GH, Mont MA. Modular taper junction corrosion and failure: how to approach a recalled total hip arthroplasty implant. J Arthroplasty. 2014;29:16.
4. Kao LW, Rusyniak DE. Chronic poisoning. Goldman-Cecil Medicine (Goldman, Schafer). 2015: Philadelphia, PA: Elsevier Saunders; 9298.
5. Agency for Toxic Substances and Diseases Registry. Available at: www/atsdr.cdc.gov. Accessed March 16, 2015.
6. Reijngoud LW, Pattyn C, De Haan R, et al. Does intraoperative cell salvage remove cobalt and chromium from reinfused blood? J Arthroplasty. 2009;24:11251129.
7. Ganapathi M, Jones S, Roberts P. P47 metal levels in ‘cell saver’ blood recovered during revision hip arthroplasty. J Bone Joint Surg. 2008;90:381
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