title: Serum titanium, niobium and aluminium levels two years  following instrumented spinal fusion in children: does implant  surface area predict serum metal ion levels?
abstract: OBJECTIVE
  Measurement of serum metal ion levels is used to determine systemic exposure to implant-derived metal debris that may be generated by processes of wear and corrosion. The aim of this study is to investigate predictors of serum metal ion levels in children undergoing instrumented spinal arthrodesis using a titanium alloy, focusing on implant characteristics and instrumentation construct design variables.
  
  
  METHODS
  This prospective longitudinal cohort study involved 33 children. Serum samples were obtained preoperatively:and at five defined interval periods over the first:two post-operative years. Samples were analysed using high resolution:inductively coupled plasma mass spectrometry to measure titanium, niobium and aluminium concentrations. Instrumentation characteristics were catalogued and construct surface area (SA) measurements calculated using an implant-specific software algorithm tool.
  
  
  RESULTS
  Significantly elevated levels of serum titanium and niobium were observed (p< 0.0001), with >95 % of post-operative levels abnormally elevated. Significant predictors of serum titanium and niobium levels included time since surgery, surgical procedure (posterior or anterior fusion), number of levels fused, number of pedicle screws inserted, total rod length, total metal SA, total exposed metal SA and total metal-on-metal SA. All significant instrumentation variables were highly correlated.
  
  
  CONCLUSIONS
  There is a strong relationship between implant SA and both serum titanium and niobium levels. The direct clinical implications of these findings for patients are uncertain, but remain of concern. Surgeons should be aware of the strong correlation between implant surface area of the chosen construct and the subsequent serum metal ion levels.
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Cundy
authors.forename: William J
authors.initials: WJ
authors.lastname: Cundy
authors.forename: Georgia
authors.initials: G
authors.lastname: Antoniou
authors.forename: Leanne M
authors.initials: LM
authors.lastname: Sutherland
authors.forename: Brian J C
authors.initials: BJ
authors.lastname: Freeman
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Cundy
mesh_terms: D000293:Adolescent; D000535:Aluminum / Q000097:blood*; D002648:Child; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D009556:Niobium / Q000097:blood*; D065289:Pedicle Screws / Q000706:statistics & numerical data; D011446:Prospective Studies; D011474:Prosthesis Design; D013123:Spinal Fusion / Q000295:instrumentation*; D014025:Titanium / Q000097:blood*
chemical_list: D009556:Niobium; D000535:Aluminum; D014025:Titanium