Titanium contamination of recycled cell saver blood in revision hip arthroplasty

Abstract

The use of Cell Saver blood during revision hip arthroplasty has many benefits, both medical and economic. After a review of the current literature, to our knowledge, no case of metallic debris has been reported in the blood after complete treatment with the Haemonetics Cell Saver (Braintree, MA) and appropriate filter system. A case of total hip revision of a loose, cemented acetabular component with a commercially pure titanium metal backing and a titanium alloy plasma-spray textured surface was undertaken. The titanium alloy femoral component was not visibly loose and was not revised. The joint lining tissues were black. Throughout the procedure, the operative site was suctioned with a double-lumen heparinized catheter that delivered blood and other materials to a Haemonetics Cell Saver 3 Plus. The reservoir and filter unit used were the compatible Bentley BCR-3500 (Baxter, Irvine, CA), a system capable of filtering particulates down to 20 μm. Prior to infusion of the salvaged blood, many large black clumps of material were observed mixed in the blood. Some measured 10 × 5 × 5 mm and could easily be seen macroscopically. Light microscopy demonstrated red blood cells with intermixed neutrophils, and black foreign material scattered as separate particles and within the cytoplasm of the scattered histiocytes. Energy dispersive analysis of the black material confirmed the composition as primarily titanium with minute quantities of copper, iron, phosphorous, and sulfer. A scanning electron photomicrograph of one of the specimens demonstrated a large conglomerate, approximately 2,000 μm in diameter, composed primarily of titanium and organic material. No malfunction in the Cell Saver machine, defects in the Cell Saver disposable components, or defects in the Bentley reservoir and filter were identified. In this case, if the individual titanium fragments did not aggregate into grossly visible particles, the contaminant likely would not have been discovered. Use of the Cell Saver in tissues with gross metallosis is not a reported contraindication. The authors suggest careful observation of the Cell Saver during the portion of revision surgery dealing with grossly blackened tissues in order to avoid aggregates of titanium as encountered in this case. Further, the authors now use a second suction not attached to the Cell Saver when grossly blackened tissues are encountered.