Hidden Toxicity of Femoral Orthopedic Implants | IJB 2026

Haroon Habib Beigh,  Nabeel Khan and Mirza Masroor Ali Beg, from the institute of the Kazakhstan. wrote a review paper about, Hidden Toxicity of Femoral Orthopedic Implants entitled, The hidden burden: A review of toxicity from femoral orthopedic implants. This research paper published by the International Journal of Biosciences | IJB. an open access scholarly research journal on Biosciences under the affiliation of the International Network For Natural Sciences | INNSpub. an open access multidisciplinary research journal publisher. 

Abstract

Locomotion is one of the essential characters of humans. During daily activity human body is subjected to several factors such as shock, stress, strain and other environmental factors. Most of times human body remains un-affected by these factors as they are contradicted by skin, fats, muscles, bones etc. But when the body is subjected to a trauma of higher impact an injury can occur which can affect capability of human body. One of the common injuries is bone fractures. Among the bone’s femur is susceptible to the fractures being the longest bone in the human body. Femoral fractures affect mobility of humans to the greater extent; in order to restore maximum function of femur, implants are used to treat fractures. Implants such as nails, Screws, plates are used to repair the bone. These implants are either made up of metals or alloys commonly used metals are titanium, gold, iron, cobalt, chromium and several others that have been reported to cause one or other toxicological episodes. Femoral fractures may take months to get treated and till the time implants are embedded in human body. Within this time frame implants start producing oxides that may result in several implications such as hypersensitivity, allergies, neurological problems and other toxicological implications. 

 

 Introduction

Femoral shaft fractures are a common orthopedic injury due to high impact trauma. The incidence of femoral shaft fracture ranges between 10 and 21 per 100,000 per year and out of these 2 percent are open fractures. The most common etiological factor is due to high or low energy mechanisms, most commonly caused by automobile accidents and falls from height. Low energy impact injuries are more common in elderly population suffering from osteoporosis (Ghouri et al., 2023). Common femoral factures are indicated in (Fig. 1).

There has been 1-9 % incidence of proximal femur fractures (femur head and neck and intertrochanteric) associated with femur shaft fractures and 20-50% of such associated fractures go unnoticed. Such associated fractures should be investigated thoroughly as they are clinically important for further management. Intramedullary nailing is the gold standard for the treatment of femoral shaft fractures. Along with the femoral shaft fractures, there is another type of femoral fracture closely associated with implants in their management. These are the femoral neck fractures which is a type of intra-capsular hip fracture. The femoral neck is the connection between the femoral head and the shaft; the head of femur articulates with the acetabulum therefore this junctional location makes the neck of femur prone to fractures. Results of annual census indicate that out of 1.6 million hip fractures annually, 70 percent of these fractures occur in women indicating a strong correlation between female gender and hip fractures (Osteoporosis Canada, 2021). Other risk factors include osteoporosis and decreased mobility. The management of such fractures depends on several factors such as Age, Displacement of fracture etc. Elderly patients with displaced fracture either undergo Hemiarthroplasty or Total hip arthroplasty depending upon their baseline activity level and age (Sansone et al., 2013).

Orthopedic implants are broadly divided into Permanent, including hip, knee, ankle, shoulder, elbow wrists and finger joints, and Temporary including wires, screws, plates and intra-medullary nails. Metallic alloys, ceramic and polymers are the principal compositional part of such implants (Ghouri et al., 2023; Al-Shalawi et al., 2023).

Titanium alloys are most commonly used in the production of orthopedic implants such as intramedullary nails and total hip femoral stem (Jacobs et al., 2001). The reason for this is that Titanium has the key properties desirable for any implanted material in the body, which is resistance to metabolism by the body and to the oxidative processes therefore not leading to production of any active metabolites. Titanium when used as an implant leads to form a thin oxidative film over the implant which is biologically inert. Stainless steel is also a component of choice in various implants and has been the earliest modern implant being used worldwide. The most commonly used alloy is 316L composed of iron, chromium, nickel and molybdenum. It’s generally used in making nails, screws and early generation intramedullary nails. Cobalt Chrome implants have also been widely used in total hip arthroplasties. It is a biological inert agent but these implants are avoided in patients with nickel allergy as it might cause metal hypersensitivity reaction (Tapscott and Wottowa, 2025).

Biocompatibility refers to how our body reacts and interacts with foreign matter. In terms of orthopedic implants, it implies how the implant will perform its function and the body has a non-pathological response to the specific implant. Majority of the implants made from stainless steel; titanium alloys and cobalt and chromium (Co-Cr) alloys have excellent biocompatibility due to their inert nature. Corrosion is also a significant factor when it comes to choosing the type of materials for implants as this process can lead to release of cytotoxic, allergenic and carcinogenic substances in the body (Al-Shalawi et al., 2023).

Chromium and Cobalt are a major component of orthopedic implants and they are also a component of several enzymes in our body. Their high doses especially Cobalt can have toxic effects on our body systems leading to several symptoms of neurological, cardiological, hematological and endocrinological nature. Cobalt (Co) toxicity can cause tinnitus, vertigo, deafness and convulsions, also it can lead to hypothyroidism, polycythemia and cardiomyopathies (Sansone et al., 2013). The incidence of such cases is low but literatures have put up case reports of Co-Cr toxicity after THR (Total Hip Replacement) surgeries. Cobalt toxicity in such cases can lead to anorexia, fatigue, auditory or ophthalmological damage (Samargandi et al., 2024).

Metal on metal configuration in hip arthroplasty significantly elevates serum Co and Cr level as several researches have indicated and this also correlated with the increase in the level of pain (Stołtny et al., 2023). There has been a case report on bilateral visual loss after multiple hip arthroplasties along with hypothyroidism and neuropathy. The patient’s Co serum level was found to be >1000 µg/L (normal range 0-0.9ng/mL). There was a decrease in visual acuity in both the eyes along with bilateral temporal optic disc pallor (Garcia et al., 2020). Aluminum toxicity can cause memory loss, gait disturbances and might lead to development of Amyotrophic Lateral Sclerosis. A metal-on-metal hip implant consisting of Co and Cr alloy have shown an unusual increased lymphocytic infiltration and plasma cell accumulation in the peri-prosthetic tissues as compared to other implants. In the case of hip arthroplasty with conventional implants there is no lymphocytic infiltration or plasma cells presence instead the inflammation is histiocytic predominant (Hallab et al., 2001).

Chronic accumulation of Aluminum in brain can lead to development of Alzheimer’s and Parkinson’s disease and in kidneys can cause fibrosis in the glomeruli and Bowman’s corpuscles (Peto, 2010; Ollivere et al., 2012). Several studies have suggested severe complications or toxicities associated with orthopedic implants or associated metals (Table 1).

Based on the type of femoral facture different set of implants can be used to modulate the fracture such as Femoral Head, Plates, Screws, Endoprosthetic Replacements, Femoral Stems and femoral Nails. Insertion and placement of implants can lead to emotional and economic distress along with discomfort in locomotion. Patients have to go for long term treatment after surgery and physiotherapy in order to walk properly.

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Article source : The hidden burden: Areview of toxicity from femoral orthopedic implants