Published online May 18, 2024. doi: 10.5312/wjo.v15.i5.386
Revised: February 14, 2024
Accepted: April 11, 2024
Published online: May 18, 2024
Processing time: 159 Days and 17.5 Hours
In this editorial, we comment on the article by Toro et al published in the recent issue of World Journal of Orthopedics. This editorial review provides a comprehensive exploration of the landscape surrounding knee arthroplasty metallosis, focusing on key aspects ranging from the mechanisms influencing susceptibility to clinical implications and advanced treatment strategies. We elucidate the complex interplay of implant design, patient-specific variables, and wear-related processes contributing to metallosis. Furthermore, we seek to shed light on diagnostic challenges, the necessity of a multidisciplinary approach, and the imperative for vigilant implant surveillance. Uni-on-uni revision, as a targeted treatment modality, is discussed, highlighting its potential to address metallosis in unicompartmental knee arthroplasty (UKA). There is a need for heightened awa
Core Tip: Metallosis is a rare but serious complication of unicompartmental knee arthroplasty. It is generally treated through surgical debridement and revision to a total knee arthroplasty. However, in the absence of critical signs of implant malpositioning, soft tissue impairment, or bone loss, it could be successfully resolved through surgical debridement and uni-on-uni revision.
- Citation: Bogdonoff YM, Amirouche F. Addressing metallosis in knee arthroplasty: From diagnostic challenges to innovative treatments. World J Orthop 2024; 15(5): 386-389
- URL: https://www.wjgnet.com/2218-5836/full/v15/i5/386.htm
- DOI: https://dx.doi.org/10.5312/wjo.v15.i5.386
Unicompartmental knee arthroplasty (UKA) has emerged as a valuable surgical intervention for patients suffering from isolated compartmental knee arthritis, offering a less invasive alternative to total knee replacement. Toro et al[1] comprehensively discussed a case of knee metallosis managed by uni-on-uni revision wherein revision of the metal back of the knee prosthesis was sufficient to improve Oxford Knee Score and reduce metal ion levels in the blood. While UKA yields positive outcomes, complications such as metallosis can present unique challenges, necessitating advanced treatment strategies for optimal patient care. Arirachakaran et al[2] detail UKA's advantages compared to total knee arthroplasty (TKA). It was identified that TKA has more postoperative complications but lower revision rates relative to UKA. In balancing these tradeoffs, clinicians need to judge the benefits of cost, revision rate, and postoperative complications for the patient. Metallosis, characterized by the accumulation of metallic debris in the joint space, can occur because of the wear and corrosion of metal components used in knee arthroplasty. In the context of UKA, this complication poses a distinctive set of issues due to the smaller implant size and limited compartment involvement. Sahan et al[3] provide a comprehensive overview of the current challenges and diagnostics of metallosis following knee arthroplasty. Mitigation strategies need to be refined both intraoperatively to prevent debris from entering the joint space and through physical therapy protocols to help prevent injury to the joint. A case report by Rajgopal et al[4] highlighted such an event wherein metallosis resulted from an atraumatic anterior cruciate ligament rupture following UKA. This highlights the importance of physical therapy postoperatively to ensure tendon healing and recovery to full range of motion. Chughtai et al[5] discuss designing and implementing a virtual reality rehabilitation system for UKA. The study found a 350% impro
Examining the current body of literature, surgical techniques, and clinical outcomes, we aim to provide a holistic understanding of the challenges posed by metallosis in UKA and shed light on the promising prospects offered by uni-on-uni revision as a viable and innovative treatment modality. Uni-on-uni revision, an innovative surgical approach, has gained prominence as an effective solution to address metallosis in the context of UKA. This revision technique involves removing and replacing the affected unicompartmental knee implant with a similar unicompartmental prosthesis. This targeted intervention aims to mitigate the challenges posed by metallosis, restore joint function, and alleviate associated symptoms, improving the overall quality of life for affected individuals. Luyet et al[6] presented a case involving anterior dislocation of the polyethylene liner 6 wk post-operation. The accompanying painful and swollen knee was further com
The clinical implications of knee arthroplasty metallosis extend across various domains, posing challenges in diagnosis, patient management, and treatment strategies. Detecting metallosis presents a unique set of diagnostic challenges due to its subtle initial presentation. Patients may exhibit nonspecific symptoms such as discomfort, joint pain, or functional limitations, often resembling common post-arthroplasty issues. Additionally, conventional imaging modalities, like X-ray, may not capture the extent of metallosis-related complications, necessitating advanced techniques such as ultrasonography for more detailed assessments. This is highlighted in an exemplary review by Mallon et al[10] in their case report, they detail the emergence of ultrasonography as a tool to differentiate joint effusion from synovitis. Herein, the importance of incorporating multiple imaging modalities is highlighted to obtain a complete picture of the knee com
Single-photon emission computed tomography with computed tomography (SPECT/CT) also emerges as a useful clinical tool for further elucidating the etiology of the pathology taking place. Metallosis emerges as a rarer complication relative to the malposition of TKA, patellofemoral osteoarthritis, infection, aseptic loosening, and arthrofibrosis. A salient article by Hirschmann et al[11] discusses the application of supplementary SPECT/CT to provide more robust image data for 100 TKA patients who were experiencing postoperative TKA pain. The diagnosis and final treatment were changed in 85 of 100 knees imaged after SPECT/CT bone tracer uptake analysis was taken into consideration. This remarkable finding underscores the effectiveness of SPECT/CT not only in pinpointing the most frequent causes of post-TKA pain but also in its capability to definitively confirm or exclude the presence of metallosis. The integration of SPECT/CT into clinical practice offers a comprehensive imaging solution that enriches the diagnostic process, leading to more tailored and effective treatment strategies for patients experiencing postoperative complications.
A multidisciplinary approach is crucial to managing metallosis, involving collaboration between orthopedic surgeons, rheumatologists, radiologists, and pathologists. This collaborative effort is essential for accurate diagnosis, tissue damage assessment, and comprehensive treatment plans. Regular surveillance of patients with knee arthroplasty becomes param
Through this exploration, we have delved into the mechanisms contributing to increased susceptibility to metallosis, the diagnostic intricacies clinicians face, and the evolving landscape of clinical management with a focus on uni-on-uni revision. As we unravel the complexities surrounding metallosis, it becomes evident that the interplay of implant design, patient-specific variables, and biological responses intricately shapes the trajectory of this complication. Acknowledging the diagnostic challenges, characterized by subtle clinical presentations and limitations in conventional imaging, reinforces the need for a multidisciplinary alliance to navigate these complexities effectively.
The clinical implications of knee arthroplasty metallosis extend beyond mere recognition, emphasizing the significance of proactive surveillance, patient education, and individualized treatment strategies. Uni-on-uni revision emerges as a promising surgical modality, providing targeted intervention for metallosis in UKA. This approach, guided by a meticulous understanding of implant-specific considerations and patient health, highlights the evolution of orthopedic interventions toward personalized care. In conclusion, the landscape of knee arthroplasty metallosis is dynamic and multifaceted. By embracing a comprehensive and patient-centered approach, clinicians can navigate the challenges posed by this complication. This approach promises to pave the way for enhanced diagnostic precision and proactive management, eventually improving outcomes for those who undergo knee arthroplasty.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Orthopedics
Country/Territory of origin: United States
Peer-review report’s scientific quality classification
Grade A (Excellent): 0
Grade B (Very good): 0
Grade C (Good): C
Grade D (Fair): 0
Grade E (Poor): 0
P-Reviewer: Anzola Fuentes LK, Colombia S-Editor: Zhang H L-Editor: A P-Editor: Zhao YQ
1. | Toro G, Braile A, Conza G, De Cicco A, Abu Mukh A, Placella G, Salini V. Unicompartimental knee arthroplasty metallosis treated with uni-on-uni revision: A case report. World J Orthop. 2023;14:889-896. [PubMed] [DOI] [Cited in This Article: ] [Reference Citation Analysis (0)] |
2. | Arirachakaran A, Choowit P, Putananon C, Muangsiri S, Kongtharvonskul J. Is unicompartmental knee arthroplasty (UKA) superior to total knee arthroplasty (TKA)? A systematic review and meta-analysis of randomized controlled trial. Eur J Orthop Surg Traumatol. 2015;25:799-806. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 95] [Cited by in F6Publishing: 115] [Article Influence: 12.8] [Reference Citation Analysis (0)] |
3. | Sahan I, Anagnostakos K. Metallosis after knee replacement: a review. Arch Orthop Trauma Surg. 2020;140:1791-1808. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 5] [Cited by in F6Publishing: 5] [Article Influence: 1.3] [Reference Citation Analysis (0)] |
4. | Rajgopal A, Panda I, Tyagi VC. Early failure with massive metallosis and posteromedial wear following atraumatic anterior cruciate ligament rupture after medial unicompartmental knee arthroplasty. Arthroplast Today. 2018;4:15-19. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 7] [Cited by in F6Publishing: 10] [Article Influence: 1.7] [Reference Citation Analysis (0)] |
5. | Chughtai M, Kelly JJ, Newman JM, Sultan AA, Khlopas A, Sodhi N, Bhave A, Kolczun MC 2nd, Mont MA. The Role of Virtual Rehabilitation in Total and Unicompartmental Knee Arthroplasty. J Knee Surg. 2019;32:105-110. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 29] [Cited by in F6Publishing: 32] [Article Influence: 6.4] [Reference Citation Analysis (0)] |
6. | Luyet A, Fischer JF, Jolles BM, Lunebourg A. Unexpected wear of an unicompartimental knee arthroplasty in oxidized zirconium. Acta Orthop Belg. 2015;81:790-795. [PubMed] [Cited in This Article: ] |
7. | Epinette JA, Leyder M, Saragaglia D, Pasquier G, Deschamps G; Société Française de la Hanche et du Genou. Is unicompartmental-to-unicompartmental revision knee arthroplasty a reliable option? Case-control study. Orthop Traumatol Surg Res. 2014;100:141-145. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 5] [Cited by in F6Publishing: 4] [Article Influence: 0.4] [Reference Citation Analysis (0)] |
8. | Matharu GS, Eskelinen A, Judge A, Pandit HG, Murray DW. Revision surgery of metal-on-metal hip arthroplasties for adverse reactions to metal debris. Acta Orthop. 2018;89:278-288. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 22] [Cited by in F6Publishing: 23] [Article Influence: 3.8] [Reference Citation Analysis (0)] |
9. | Schiavone Panni A, Vasso M, Cerciello S, Maccauro G. Metallosis following knee arthroplasty: a histological and immunohistochemical study. Int J Immunopathol Pharmacol. 2011;24:711-719. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 17] [Cited by in F6Publishing: 17] [Article Influence: 1.3] [Reference Citation Analysis (0)] |
10. | Mallon S, Bussis K, Beswick Z, North WT, Soliman SB. Ultrasonographic and radiographic findings of polyethylene component displacement with severe metallosis and metal-induced synovitis following total knee arthroplasty. Knee. 2019;26:941-950. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 8] [Cited by in F6Publishing: 7] [Article Influence: 1.4] [Reference Citation Analysis (0)] |
11. | Hirschmann MT, Amsler F, Rasch H. Clinical value of SPECT/CT in the painful total knee arthroplasty (TKA): a prospective study in a consecutive series of 100 TKA. Eur J Nucl Med Mol Imaging. 2015;42:1869-1882. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 47] [Cited by in F6Publishing: 47] [Article Influence: 5.2] [Reference Citation Analysis (0)] |