Detection of metal ions in hair after metal–metal hip arthroplasty | Revista Española de Cirugía Ortopédica y Traumatología (English Edition)

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Hernandez-Vaquero, M. Rodríguez de la Flor, J.M. Fernandez-Carreira, C. Sariego-Muñiz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Hernandez-Vaquero" "email" => array:1 [ 0 => "danielhvaquero@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Rodríguez de la Flor" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J.M." "apellidos" => "Fernandez-Carreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Sariego-Muñiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Hospital San Agustín, Avilés, Departamento de Cirugía, Facultad de Medicina, Universidad de Oviedo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Farmacia Hospitalaria, Hospital San Agustín, Avilés, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Investigación, Hospital San Agustín, Avilés, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Espectrometría de Masas, Servicios Científico-Técnicos de Investigación, Universidad de Oviedo, Oviedo, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Detección de iones metálicos en cabello tras artroplastia de cadera metal-metal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1750 "Ancho" => 2163 "Tamanyo" => 111080 ] ] "descripcion" => array:1 [ "en" => "Levels of metals in hair (in ppm) during follow-up at 3 and 6 years." ] ] ] "textoCompleto" => "IntroductionThe main long-term complication in hip arthroplasties is wear of components, followed by onset of osteolysis and, ultimately, failure caused by mobilization of components. In recent years, the search for solutions to this problem, especially worrying among young patients, has led to the introduction of new polyethylenes, some new designs and a re-emergence of metal–metal (M-M) friction couplings. It is known that some M-M arthroplasty models may produce various clinical conditions resulting from the presence of metal ions in blood and urine, particularly chromium (Cr) and cobalt (Co). Although no cases of cancer or fetal complications have been reported to date, high levels of these metals can cause kidney and liver disorders, as well as local lesions, such as cysts and pseudotumors known as ALVAL (aseptic lymphocyte-dominant vasculitis-associated lesion).<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> In addition to Cr and Co, other metals, like molybdenum (Mo), are also employed in the manufacture of these models. Nevertheless, it is striking how little impact the elevation of the levels of this metal has had in the abundant literature on these models, considering that elevated levels of Mo can cause negative effects on fertility. This is important when we take into account that the population group eligible for implantation of a hip prosthesis of this type includes young patients, and therefore, has implications at a reproductive level.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Different follow-up protocols have been published including guidelines for normal levels of metal ions in blood and urine, maximum admissible levels<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and the importance of monitoring. These analytical determinations require special care in the collection and transfer of samples and are not routinely performed by the laboratories of general hospitals. Moreover, they can occasionally be altered by the intake of certain foods, the contribution of certain drugs and environmental conditions.Hair has a remarkable potential as a biomarker, as it reflects historical exposure to various substances, including heavy metals.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Its use in the determination of metal levels avoids invasive measurements and discomfort for patients, is independent of occasional situations and shows the true level of intoxication that these ions can cause. The levels among the general population are known to range between 0.11 and 0.52ppm for Cr, 0.004 and 0.14ppm for Co, and 0.01 and 0.028ppm for Mo,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> so their determination can be used as an indicator of metal poisoning caused by metal–metal arthroplasties, with a high level of agreement.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> The objectives of our study were:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.To know whether the hair of patients with M-M hip prostheses presented an elevated presence of metals.</li><li class="elsevierStyleListItem" id="lsti0010">2.To study the variation in these figures depending on the period elapsed since implantation.</li><li class="elsevierStyleListItem" id="lsti0015">3.To assess whether the figures for metals in hair decreased by removing M-M arthroplasties, through revision surgery.</li></ul>Materials and methodsThis work was part of a comparative study of diagnostic and consistency tests in the monitoring of Co and Cr levels in serum and urine and Cr, Co and Mo in hair obtained from 45 patients with De Puy™ ASR hip resurfacing metal–metal prostheses (De Puy Orthopedics Inc., Warsaw, IN, USA). The arthroplasties were implanted during the period between 2006 and 2009. The study was approved by the Regional Ethics Committee (reference number 037/2011) and all patients signed an informed consent form for the use of their blood, urine and hair, as well as their clinical and imaging data. The initial series consisted of 49 arthroplasties, but 1 case was a bilateral implant so it was removed on suspicion that its determinations could introduce a confounding bias. A further 2 arthroplasties were lost during follow-up.The mean age was 57.5±9.05 years (range: 35–76 years) and the mean BMI was 29.42±5.37 (range: 19.48–43.58). Two patients were female and the remaining 43 were males. At the time the study was conducted, a mean period of 51.8 months (range: 29–85 months) had elapsed since the arthroplasty was implanted. During the follow-up period, revision surgery was performed to remove the surface arthroplasty in 11 cases; 2 cases due to fractures of the femoral neck, 1 due to recurrent dislocation, 5 due to high metal levels and presence of a periarticular cyst confirmed by magnetic resonance and 3 due to local pain with an unexplained cause. A conventional model with metal–polyethylene friction was implanted in these patients and they abandoned the study. However, a determination of metal ions in hair was carried out at 12 months of this second intervention.Hair samples were taken less than 4cm away from the skin in the right side of the head of each patient, with samples weighing at least 0.5g, following the recommendations established by several validated studies. The samples were sent to the laboratory in polyethylene bags identified by random numbers.Hair analysis consisted of several phases. In the pretreatment stage, the samples were conditioned by a process involving washing in an ultrasonic bath to remove traces adhered to the surface that could alter the results. After this process, samples were introduced in an oven at 50°C for 12h. Dry samples were stored at room temperature until analysis. The samples were stored at −20°C until their analysis, which was performed through the inductively coupled plasma mass spectrometry (ICP-MS) technique.Quantification of metals was carried out using an Element high-resolution mass spectrometer (Thermo Fisher, Inc., Waltham, MA, USA). This device was equipped with a Meinhard type concentric nebulizer, an uncooled Scott type double-pass nebulizing chamber, a Fassel type torch with a 1mm internal diameter injector tube and 2 nickel interface cones, a sampler and a skimmer. It offered 3 different resolution levels, which were predefined and selectable at the time of executing a study.The data analysis was carried out using the statistical package SPSS for Windows version 20 (SPSS Inc., Chicago, IL, USA). Comparisons of metals according to years of follow-up were carried out through the nonparametric Kruskal–Wallis test. The significance level for statistical differences was defined at P<.05.ResultsDeterminations of Cr, Co and Mo in hair in our series reached very high levels (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). No significant differences in metal concentrations were detected according to the follow-up time in years (Kruskal–Wallis). Both Cr and Co increased at 4 years, decreased at 5 and rose again at 6. However, Mo decreased progressively after 4 years (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>In order to determine whether the levels of these ions in hair were modified by removing the implant, we specifically studied the group of 11 patients who were reoperated, comparing the levels of metals before and after the revision surgery (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). We observed significant differences in the decrease of Cr and Mo levels, and a trend toward significance in the case of Co. By exclusively studying the 5 patients who were reoperated due to metallosis we were able to observe a considerable difference between the measurements carried out before and after revision surgery, which represented a 43.8% decrease in the levels of Cr, 51.1% in Mo and 90.3% in Co (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>DiscussionThe release of metal ions from M-M hip prostheses, especially in surface models, is one of the best studied types of exposure to metals, especially since local tissue reactions were detected.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The importance of studying the consequences of this release is increased by the fact that one third of hip surgeries performed in the US during 2009 employed M-M prostheses and that there are over 500,000 patients carrying these types of prostheses in the country, most of them implanted between 2003 and 2010. Over a million M-M hip joints have been implanted worldwide since 1996.Although metal contamination with an internal origin has shown no teratogenic or carcinogenic effects so far, poisoning from external sources has been associated with different effects on reproduction, renal and cardiac function. There have also been reports of bone marrow, spleen and liver alterations among patients with M-M friction arthroplasties. The most commonly affected systems and organs in the medium-term (10–20 years) are the hematopoietic and urogenital systems and the skin. In the long-term (20–40 years), solid organs can be affected,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> but in comparison with other types of implants there is no evidence that M-M surface implants are associated with an increased risk of cancer diagnosis in the 7 years following the intervention.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Due to these effects, and especially to the possibility of unknown medium- and long-term complications, regular monitoring has been recommended in patients with an M-M arthroplasty<a class="elsevierStyleCrossRefs" href="#bib0050">10–12</a> and especially in those with hip surface models. The ASR model has shown a high rate of medium-term failures,<a class="elsevierStyleCrossRef" href="#bib0065">13</a> which has led international agencies<a class="elsevierStyleCrossRef" href="#bib0070">14</a> and the manufacturing company itself to recommend its withdrawal from clinical practice since 2010.The main objective of our study was to know whether these models of M-M hip prostheses were associated with higher levels of metal detection in hair compared to the normal population and also to investigate whether removing the implant decreased those levels.The study of metals in hair was carried out to assess their relationship with the development of certain diseases, such as Parkinson's, fibromyalgia, autism, schizophrenia, multiple sclerosis, etc.<a class="elsevierStyleCrossRefs" href="#bib0075">15–20</a>There are various techniques available for the analysis of trace metals in hair,<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> including anodic dissolution voltammetry, X-ray fluorescence, spectroscopic elemental analysis by energy dispersion through an electron detector coupled to a scanning microscope, neutron activation analysis, attenuated total reflectance Fourier transform infrared, synchrotron radiation and ICP-MS. In our study we used ICP-MS because it is a new generation qualitative and quantitative technique which offers high resolution, is extensively validated and is cost-effective compared to the more novel synchrotron radiation technique.Several studies<a class="elsevierStyleCrossRefs" href="#bib0115">23–25</a> have shown that levels of metals accumulated at concentrations above 10–50% in hair and their determination enable the analysis of the historical exposure of a patient, and not just the release of ions, which fluctuates over time. Hair is a slow-growing tissue, so it does not reflect rapid fluctuations in the levels of metals, but in order to assess the state of health it is more desirable to know the tissue load of metals than the amount being transported at a given time. The normal amounts of metals in the hair of unexposed populations are well known, including some small variability due to the use of different equipment for their determination.<a class="elsevierStyleCrossRefs" href="#bib0130">26–33</a> The figures for Cr in hair range between 0.46 and 1.16ppm, those for Co between 0.06 and 1.67ppm and those for Mo between 0.12 and 0.55ppm. As can be seen (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), the figures in our series were much higher, and this can only be due to internal contamination produced by the prosthetic models.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>In animals, continued exposure to Mo has originated fatty degeneration in the liver and kidneys, as well as altered levels of group B vitamins.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> Mo is a cofactor for several enzymes (xanthine oxidase, aldehyde oxidase, sulfite oxidase) and its presence is necessary for protein metabolism, sulfur metabolism, hydrolysis of phosphate esters and the transport and utilization of iron. Mammalian studies have observed different toxic effects derived from a high presence of this metal, particularly weight loss, diarrhea, alopecia and anemia. Its reproductive toxicity is known since the mid-twentieth century and several studies have proven gonadal involvement at a morphological and functional level (decreased sperm concentration, motility and morphological alterations), as well as embryotoxicity of male origin.The ultimate objective of our study was to determine whether the levels of metals in hair decreased by removing M-M arthroplasties. We observed that these levels decreased after removing the prostheses among cases suffering metallosis. The decrease was over 40% in the levels of Cr, 50% in Mo and 90% in Co.However, although we observed that the figures dropped considerably after revision surgery, they did not return to normal levels 1 year after the second intervention. This may be due to the effect of metal deposition and will presumably decrease over time. Another explanation may be that the new, metal–polyethylene friction implants also increase circulating metal levels.The determination of metals in hair has several advantages. Its analysis does not require specific technical personnel to obtain samples, which can even be provided by patients themselves, thus avoiding the costs of specific healthcare staff and equipment for collection. There is no need to maintain the cold chain and the samples can be stored at room temperature for a long time without changes in composition. The determination of metals in hair is a low cost technique which also offers indirect savings, as patients do not need to visit healthcare centers during business hours as is unavoidably the case for blood collection and delivery of urine samples. Moreover, it also prevents the exposure of healthcare staff to biological fluids which could represent a medium for transmission of infections. Furthermore, an incorrect extraction and transport of blood samples can alter the results, whilst urine tests are tedious for patients, since they require the urine of 24h, which implies discomfort and increases uncertainty about the correct collection of samples, as there is no technical staff present. Both fluids require specific material for transport and storage of samples, and the cold chain must be maintained at all times.The limitations of our study are, firstly, the absence of a control group; we have accepted the levels of metals in the hair of a normal population described in the literature and we have noted the considerable difference between the published figures and those obtained in our work. We do not know if metal levels in hair also increase with models of arthroplasties using other types of friction, like metal–polyethylene, but this does not invalidate the results obtained. Our series included few patients and a limited follow-up period. Due to the small number of patients who underwent revision surgery, the decrease in the levels of metals in hair could offer no statistical differences. However, the extraordinarily large differences between the measurements before and after implant removal confirmed that the levels of these metals in hair were modified through the placement and subsequent removal of M-M arthroplasties. A final limitation of our study is the absence of a link between metal levels in hair and general or local alterations in the medium- and long-term, which can only be established with the passage of time.The results of our study show that the levels of Cr, Co and Mo in the hair of patients with this type of arthroplasty are higher than among the normal population, and that they decrease following implant removal. This indicates that this determination is a good biological indicator for the monitoring and study of the toxicokinetic behavior of metals released by M-M hip prostheses. This simple determination can be useful to screen for metal poisoning from joint prostheses among large populations, which can subsequently be monitored by standardized determinations in serum and urine.Level of evidenceLevel of evidence iii.Ethical responsibilitiesProtection of people and animalsThe authors declare that this investigation adhered to the ethical guidelines of the Committee on Responsible Human Experimentation, as well as the World Medical Association and the Declaration of Helsinki.Confidentiality of dataThe authors declare that they have followed the protocols of their workplace on the publication of patient data and that all patients included in the study received sufficient information and gave their written informed consent to participate in the study.Right to privacy and informed consentThe authors declare that this work does not reflect any patient data.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres366172" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec345811" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres366173" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y método" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec345810" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Level of evidence" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack91325" "titulo" => "Acknowledgement" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-01-13" "fechaAceptado" => "2014-01-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec345811" "palabras" => array:3 [ 0 => "Hip surface replacement" 1 => "Metal–metal prosthesis" 2 => "Metals in hair" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec345810" "palabras" => array:3 [ 0 => "Artroplastias de superficie de cadera" 1 => "Prótesis metal-metal" 2 => "Metales en cabello" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveThere is an increase in the levels of metals in the serum and urine after the implantation of some models of metal–metal hip prosthesis. It has recently been demonstrated that there is an association between these levels and the levels found in hair. The aim of this study is to determine the presence of metals in hair, and to find out whether these change over time or with the removal of the implant. Materials and methodsThe levels of chromium, cobalt and molybdenum were determined in the hair of 45 patients at 3, 4, 5, and 6 years after a hip surface replacement. The mean age was 57.5 years, and two were female. Further surgery was required to remove the replacement and implant a new model with metal–polyethylene friction in 11 patients, 5 of them due to metallosis and a periarticular cyst. ResultsThe mean levels of metals in hair were chromium 163.27ppm, cobalt 61.98ppm, and molybdenum 31.36ppm, much higher than the levels found in the general population. A decrease in the levels of chromium (43.8%), molybdenum (51.1%), and cobalt (91.1%) was observed at one year in the patients who had further surgery to remove the prosthesis. ConclusionsHigh concentrations of metals in the hair are observed in hip replacements with metal–metal friction, which decrease when that implant is removed. The determination of metal ions in hair could be a good marker of the metal poisoning that occurs in these arthroplasty models." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivoTras el implante de algunos modelos de prótesis de cadera metal-metal se produce una elevación de los niveles de metales en suero y orina. Recientemente se ha demostrado que hay concordancia entre estas cifras y los niveles encontrados en el cabello. Nuestro objetivo ha sido estudiar la presencia de metales en cabello y conocer si ello se modifica con el paso del tiempo o con la extracción del implante. Material y métodoEn 45 pacientes con una artroplastia de superficie se ha realizado una determinación de los niveles de cromo, cobalto y molibdeno en cabello a los 3, 4, 5 y 6 años desde el implante. La edad media fue de 57,5 años, 2 eran mujeres. En 11 pacientes, en 5 de ellos por metalosis y quiste periarticular, fue necesaria una reintervención para extracción de la artroplastia e implante de un nuevo modelo con fricción metal-polietileno. ResultadosLas cifras medias de metales en cabello fueron cromo 163,27ppm, cobalto 61,98ppm y molibdeno 31,36ppm, muy por encima de los niveles referidos en la población general. En los pacientes reintervenidos para extracción de la artroplastia se observó al año de la intervención una disminución del 43,8% en los niveles de cromo, del 51,1% en molibdeno y del 90,3% en cobalto. ConclusionesEn las artroplastias de cadera con fricción metal-metal se aprecia una alta concentración de metales en el cabello, que disminuye cuando dicho implante es extraído. La determinación de iones en cabello puede ser un buen marcador de la intoxicación por metales que sucede en estos modelos artroplásticos." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Hernandez-Vaquero D, Rodríguez de la Flor M, Fernandez-Carreira JM, Sariego-Muñiz C. Detección de iones metálicos en cabello tras artroplastia de cadera metal-metal. Rev Esp Cir Ortop Traumatol. 2014;58:267–273." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1750 "Ancho" => 2163 "Tamanyo" => 111080 ] ] "descripcion" => array:1 [ "en" => "Levels of metals in hair (in ppm) during follow-up at 3 and 6 years." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1390 "Ancho" => 2475 "Tamanyo" => 88040 ] ] "descripcion" => array:1 [ "en" => "Levels of metals (in ppm) before and after revision surgery in cases of metallosis." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "SD: standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">95% confidence interval</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Variation coefficient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maximum \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Lower limit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Upper limit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">163.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">262.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">300.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1616.30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Co \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">106.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">126.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">618.80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">222.10 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab550217.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Levels of metals in hair (in ppm)." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "SD: standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Before revision surgery</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">After revision surgery</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">P<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cr in hair \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">185.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">226.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.70–683.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">102.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">132.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.00–396.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.028 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Co in hair \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">147.40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">233.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.70–618.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.30–205.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.249 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mo in hair \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.90–74.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.80–35.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.043 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab550216.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "Wilcoxon test." ] ] ] "descripcion" => array:1 [ "en" => "Comparative results following implant extraction (in ppm)." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Goullé et al.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Nowak<a class="elsevierStyleCrossRef" href="#bib0140">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Davies et al.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Batzevich<a class="elsevierStyleCrossRef" href="#bib0150">30</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Elenge et al.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Miekeley et al.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Ray et al.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Current series \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Co – mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61.97 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cr – mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">163.27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mo – mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.36 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab550218.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Figures for metals in hair (in ppm) for the normal population and in our series." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" 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Original Article

Detection of metal ions in hair after metal–metal hip arthroplasty

Detección de iones metálicos en cabello tras artroplastia de cadera metal-metal

D. Hernandez-Vaqueroa,

Corresponding author

danielhvaquero@gmail.com

Corresponding author.

, M. Rodríguez de la Florb, J.M. Fernandez-Carreirac, C. Sariego-Muñizd

a Servicio de Cirugía Ortopédica y Traumatología, Hospital San Agustín, Avilés, Departamento de Cirugía, Facultad de Medicina, Universidad de Oviedo, Spain

b Servicio de Farmacia Hospitalaria, Hospital San Agustín, Avilés, Spain

c Unidad de Investigación, Hospital San Agustín, Avilés, Spain

d Unidad de Espectrometría de Masas, Servicios Científico-Técnicos de Investigación, Universidad de Oviedo, Oviedo, Spain

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        "titulo" => "Detecci&#243;n de iones met&#225;licos en cabello tras artroplastia de cadera metal-metal"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Levels of metals in hair &#40;in ppm&#41; during follow-up at 3 and 6 years&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The main long-term complication in hip arthroplasties is wear of components&#44; followed by onset of osteolysis and&#44; ultimately&#44; failure caused by mobilization of components&#46; In recent years&#44; the search for solutions to this problem&#44; especially worrying among young patients&#44; has led to the introduction of new polyethylenes&#44; some new designs and a re-emergence of metal&#8211;metal &#40;M-M&#41; friction couplings&#46; It is known that some M-M arthroplasty models may produce various clinical conditions resulting from the presence of metal ions in blood and urine&#44; particularly chromium &#40;Cr&#41; and cobalt &#40;Co&#41;&#46; Although no cases of cancer or fetal complications have been reported to date&#44; high levels of these metals can cause kidney and liver disorders&#44; as well as local lesions&#44; such as cysts and pseudotumors known as ALVAL &#40;aseptic lymphocyte-dominant vasculitis-associated lesion&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> In addition to Cr and Co&#44; other metals&#44; like molybdenum &#40;Mo&#41;&#44; are also employed in the manufacture of these models&#46; Nevertheless&#44; it is striking how little impact the elevation of the levels of this metal has had in the abundant literature on these models&#44; considering that elevated levels of Mo can cause negative effects on fertility&#46; This is important when we take into account that the population group eligible for implantation of a hip prosthesis of this type includes young patients&#44; and therefore&#44; has implications at a reproductive level&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Different follow-up protocols have been published including guidelines for normal levels of metal ions in blood and urine&#44; maximum admissible levels<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and the importance of monitoring&#46; These analytical determinations require special care in the collection and transfer of samples and are not routinely performed by the laboratories of general hospitals&#46; Moreover&#44; they can occasionally be altered by the intake of certain foods&#44; the contribution of certain drugs and environmental conditions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Hair has a remarkable potential as a biomarker&#44; as it reflects historical exposure to various substances&#44; including heavy metals&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Its use in the determination of metal levels avoids invasive measurements and discomfort for patients&#44; is independent of occasional situations and shows the true level of intoxication that these ions can cause&#46; The levels among the general population are known to range between 0&#46;11 and 0&#46;52<span class="elsevierStyleHsp" style=""></span>ppm for Cr&#44; 0&#46;004 and 0&#46;14<span class="elsevierStyleHsp" style=""></span>ppm for Co&#44; and 0&#46;01 and 0&#46;028<span class="elsevierStyleHsp" style=""></span>ppm for Mo&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> so their determination can be used as an indicator of metal poisoning caused by metal&#8211;metal arthroplasties&#44; with a high level of agreement&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The objectives of our study were&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0020" class="elsevierStylePara elsevierViewall">To know whether the hair of patients with M-M hip prostheses presented an elevated presence of metals&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">To study the variation in these figures depending on the period elapsed since implantation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">To assess whether the figures for metals in hair decreased by removing M-M arthroplasties&#44; through revision surgery&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">This work was part of a comparative study of diagnostic and consistency tests in the monitoring of Co and Cr levels in serum and urine and Cr&#44; Co and Mo in hair obtained from 45 patients with De Puy&#8482; ASR hip resurfacing metal&#8211;metal prostheses &#40;De Puy Orthopedics Inc&#46;&#44; Warsaw&#44; IN&#44; USA&#41;&#46; The arthroplasties were implanted during the period between 2006 and 2009&#46; The study was approved by the Regional Ethics Committee &#40;reference number 037&#47;2011&#41; and all patients signed an informed consent form for the use of their blood&#44; urine and hair&#44; as well as their clinical and imaging data&#46; The initial series consisted of 49 arthroplasties&#44; but 1 case was a bilateral implant so it was removed on suspicion that its determinations could introduce a confounding bias&#46; A further 2 arthroplasties were lost during follow-up&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The mean age was 57&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;05 years &#40;range&#58; 35&#8211;76 years&#41; and the mean BMI was 29&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;37 &#40;range&#58; 19&#46;48&#8211;43&#46;58&#41;&#46; Two patients were female and the remaining 43 were males&#46; At the time the study was conducted&#44; a mean period of 51&#46;8 months &#40;range&#58; 29&#8211;85 months&#41; had elapsed since the arthroplasty was implanted&#46; During the follow-up period&#44; revision surgery was performed to remove the surface arthroplasty in 11 cases&#59; 2 cases due to fractures of the femoral neck&#44; 1 due to recurrent dislocation&#44; 5 due to high metal levels and presence of a periarticular cyst confirmed by magnetic resonance and 3 due to local pain with an unexplained cause&#46; A conventional model with metal&#8211;polyethylene friction was implanted in these patients and they abandoned the study&#46; However&#44; a determination of metal ions in hair was carried out at 12 months of this second intervention&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Hair samples were taken less than 4<span class="elsevierStyleHsp" style=""></span>cm away from the skin in the right side of the head of each patient&#44; with samples weighing at least 0&#46;5<span class="elsevierStyleHsp" style=""></span>g&#44; following the recommendations established by several validated studies&#46; The samples were sent to the laboratory in polyethylene bags identified by random numbers&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Hair analysis consisted of several phases&#46; In the pretreatment stage&#44; the samples were conditioned by a process involving washing in an ultrasonic bath to remove traces adhered to the surface that could alter the results&#46; After this process&#44; samples were introduced in an oven at 50<span class="elsevierStyleHsp" style=""></span>&#176;C for 12<span class="elsevierStyleHsp" style=""></span>h&#46; Dry samples were stored at room temperature until analysis&#46; The samples were stored at &#8722;20<span class="elsevierStyleHsp" style=""></span>&#176;C until their analysis&#44; which was performed through the inductively coupled plasma mass spectrometry &#40;ICP-MS&#41; technique&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Quantification of metals was carried out using an Element high-resolution mass spectrometer &#40;Thermo Fisher&#44; Inc&#46;&#44; Waltham&#44; MA&#44; USA&#41;&#46; This device was equipped with a Meinhard type concentric nebulizer&#44; an uncooled Scott type double-pass nebulizing chamber&#44; a Fassel type torch with a 1<span class="elsevierStyleHsp" style=""></span>mm internal diameter injector tube and 2 nickel interface cones&#44; a sampler and a skimmer&#46; It offered 3 different resolution levels&#44; which were predefined and selectable at the time of executing a study&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The data analysis was carried out using the statistical package SPSS for Windows version 20 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46; Comparisons of metals according to years of follow-up were carried out through the nonparametric Kruskal&#8211;Wallis test&#46; The significance level for statistical differences was defined at <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">Determinations of Cr&#44; Co and Mo in hair in our series reached very high levels &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; No significant differences in metal concentrations were detected according to the follow-up time in years &#40;Kruskal&#8211;Wallis&#41;&#46; Both Cr and Co increased at 4 years&#44; decreased at 5 and rose again at 6&#46; However&#44; Mo decreased progressively after 4 years &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In order to determine whether the levels of these ions in hair were modified by removing the implant&#44; we specifically studied the group of 11 patients who were reoperated&#44; comparing the levels of metals before and after the revision surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; We observed significant differences in the decrease of Cr and Mo levels&#44; and a trend toward significance in the case of Co&#46; By exclusively studying the 5 patients who were reoperated due to metallosis we were able to observe a considerable difference between the measurements carried out before and after revision surgery&#44; which represented a 43&#46;8&#37; decrease in the levels of Cr&#44; 51&#46;1&#37; in Mo and 90&#46;3&#37; in Co &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The release of metal ions from M-M hip prostheses&#44; especially in surface models&#44; is one of the best studied types of exposure to metals&#44; especially since local tissue reactions were detected&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The importance of studying the consequences of this release is increased by the fact that one third of hip surgeries performed in the US during 2009 employed M-M prostheses and that there are over 500&#44;000 patients carrying these types of prostheses in the country&#44; most of them implanted between 2003 and 2010&#46; Over a million M-M hip joints have been implanted worldwide since 1996&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Although metal contamination with an internal origin has shown no teratogenic or carcinogenic effects so far&#44; poisoning from external sources has been associated with different effects on reproduction&#44; renal and cardiac function&#46; There have also been reports of bone marrow&#44; spleen and liver alterations among patients with M-M friction arthroplasties&#46; The most commonly affected systems and organs in the medium-term &#40;10&#8211;20 years&#41; are the hematopoietic and urogenital systems and the skin&#46; In the long-term &#40;20&#8211;40 years&#41;&#44; solid organs can be affected&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> but in comparison with other types of implants there is no evidence that M-M surface implants are associated with an increased risk of cancer diagnosis in the 7 years following the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Due to these effects&#44; and especially to the possibility of unknown medium- and long-term complications&#44; regular monitoring has been recommended in patients with an M-M arthroplasty<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> and especially in those with hip surface models&#46; The ASR model has shown a high rate of medium-term failures&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> which has led international agencies<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and the manufacturing company itself to recommend its withdrawal from clinical practice since 2010&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The main objective of our study was to know whether these models of M-M hip prostheses were associated with higher levels of metal detection in hair compared to the normal population and also to investigate whether removing the implant decreased those levels&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The study of metals in hair was carried out to assess their relationship with the development of certain diseases&#44; such as Parkinson&#39;s&#44; fibromyalgia&#44; autism&#44; schizophrenia&#44; multiple sclerosis&#44; etc&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;20</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">There are various techniques available for the analysis of trace metals in hair&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> including anodic dissolution voltammetry&#44; X-ray fluorescence&#44; spectroscopic elemental analysis by energy dispersion through an electron detector coupled to a scanning microscope&#44; neutron activation analysis&#44; attenuated total reflectance Fourier transform infrared&#44; synchrotron radiation and ICP-MS&#46; In our study we used ICP-MS because it is a new generation qualitative and quantitative technique which offers high resolution&#44; is extensively validated and is cost-effective compared to the more novel synchrotron radiation technique&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Several studies<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;25</span></a> have shown that levels of metals accumulated at concentrations above 10&#8211;50&#37; in hair and their determination enable the analysis of the historical exposure of a patient&#44; and not just the release of ions&#44; which fluctuates over time&#46; Hair is a slow-growing tissue&#44; so it does not reflect rapid fluctuations in the levels of metals&#44; but in order to assess the state of health it is more desirable to know the tissue load of metals than the amount being transported at a given time&#46; The normal amounts of metals in the hair of unexposed populations are well known&#44; including some small variability due to the use of different equipment for their determination&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#8211;33</span></a> The figures for Cr in hair range between 0&#46;46 and 1&#46;16<span class="elsevierStyleHsp" style=""></span>ppm&#44; those for Co between 0&#46;06 and 1&#46;67<span class="elsevierStyleHsp" style=""></span>ppm and those for Mo between 0&#46;12 and 0&#46;55<span class="elsevierStyleHsp" style=""></span>ppm&#46; As can be seen &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; the figures in our series were much higher&#44; and this can only be due to internal contamination produced by the prosthetic models&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">In animals&#44; continued exposure to Mo has originated fatty degeneration in the liver and kidneys&#44; as well as altered levels of group B vitamins&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Mo is a cofactor for several enzymes &#40;xanthine oxidase&#44; aldehyde oxidase&#44; sulfite oxidase&#41; and its presence is necessary for protein metabolism&#44; sulfur metabolism&#44; hydrolysis of phosphate esters and the transport and utilization of iron&#46; Mammalian studies have observed different toxic effects derived from a high presence of this metal&#44; particularly weight loss&#44; diarrhea&#44; alopecia and anemia&#46; Its reproductive toxicity is known since the mid-twentieth century and several studies have proven gonadal involvement at a morphological and functional level &#40;decreased sperm concentration&#44; motility and morphological alterations&#41;&#44; as well as embryotoxicity of male origin&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The ultimate objective of our study was to determine whether the levels of metals in hair decreased by removing M-M arthroplasties&#46; We observed that these levels decreased after removing the prostheses among cases suffering metallosis&#46; The decrease was over 40&#37; in the levels of Cr&#44; 50&#37; in Mo and 90&#37; in Co&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">However&#44; although we observed that the figures dropped considerably after revision surgery&#44; they did not return to normal levels 1 year after the second intervention&#46; This may be due to the effect of metal deposition and will presumably decrease over time&#46; Another explanation may be that the new&#44; metal&#8211;polyethylene friction implants also increase circulating metal levels&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The determination of metals in hair has several advantages&#46; Its analysis does not require specific technical personnel to obtain samples&#44; which can even be provided by patients themselves&#44; thus avoiding the costs of specific healthcare staff and equipment for collection&#46; There is no need to maintain the cold chain and the samples can be stored at room temperature for a long time without changes in composition&#46; The determination of metals in hair is a low cost technique which also offers indirect savings&#44; as patients do not need to visit healthcare centers during business hours as is unavoidably the case for blood collection and delivery of urine samples&#46; Moreover&#44; it also prevents the exposure of healthcare staff to biological fluids which could represent a medium for transmission of infections&#46; Furthermore&#44; an incorrect extraction and transport of blood samples can alter the results&#44; whilst urine tests are tedious for patients&#44; since they require the urine of 24<span class="elsevierStyleHsp" style=""></span>h&#44; which implies discomfort and increases uncertainty about the correct collection of samples&#44; as there is no technical staff present&#46; Both fluids require specific material for transport and storage of samples&#44; and the cold chain must be maintained at all times&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The limitations of our study are&#44; firstly&#44; the absence of a control group&#59; we have accepted the levels of metals in the hair of a normal population described in the literature and we have noted the considerable difference between the published figures and those obtained in our work&#46; We do not know if metal levels in hair also increase with models of arthroplasties using other types of friction&#44; like metal&#8211;polyethylene&#44; but this does not invalidate the results obtained&#46; Our series included few patients and a limited follow-up period&#46; Due to the small number of patients who underwent revision surgery&#44; the decrease in the levels of metals in hair could offer no statistical differences&#46; However&#44; the extraordinarily large differences between the measurements before and after implant removal confirmed that the levels of these metals in hair were modified through the placement and subsequent removal of M-M arthroplasties&#46; A final limitation of our study is the absence of a link between metal levels in hair and general or local alterations in the medium- and long-term&#44; which can only be established with the passage of time&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The results of our study show that the levels of Cr&#44; Co and Mo in the hair of patients with this type of arthroplasty are higher than among the normal population&#44; and that they decrease following implant removal&#46; This indicates that this determination is a good biological indicator for the monitoring and study of the toxicokinetic behavior of metals released by M-M hip prostheses&#46; This simple determination can be useful to screen for metal poisoning from joint prostheses among large populations&#44; which can subsequently be monitored by standardized determinations in serum and urine&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Level of evidence</span><p id="par0140" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">iii</span>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of people and animals</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that this investigation adhered to the ethical guidelines of the Committee on Responsible Human Experimentation&#44; as well as the World Medical Association and the Declaration of Helsinki&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data and that all patients included in the study received sufficient information and gave their written informed consent to participate in the study&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that this work does not reflect any patient data&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">There is an increase in the levels of metals in the serum and urine after the implantation of some models of metal&#8211;metal hip prosthesis&#46; It has recently been demonstrated that there is an association between these levels and the levels found in hair&#46; The aim of this study is to determine the presence of metals in hair&#44; and to find out whether these change over time or with the removal of the implant&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The levels of chromium&#44; cobalt and molybdenum were determined in the hair of 45 patients at 3&#44; 4&#44; 5&#44; and 6 years after a hip surface replacement&#46; The mean age was 57&#46;5 years&#44; and two were female&#46; Further surgery was required to remove the replacement and implant a new model with metal&#8211;polyethylene friction in 11 patients&#44; 5 of them due to metallosis and a periarticular cyst&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The mean levels of metals in hair were chromium 163&#46;27<span class="elsevierStyleHsp" style=""></span>ppm&#44; cobalt 61&#46;98<span class="elsevierStyleHsp" style=""></span>ppm&#44; and molybdenum 31&#46;36<span class="elsevierStyleHsp" style=""></span>ppm&#44; much higher than the levels found in the general population&#46; A decrease in the levels of chromium &#40;43&#46;8&#37;&#41;&#44; molybdenum &#40;51&#46;1&#37;&#41;&#44; and cobalt &#40;91&#46;1&#37;&#41; was observed at one year in the patients who had further surgery to remove the prosthesis&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">High concentrations of metals in the hair are observed in hip replacements with metal&#8211;metal friction&#44; which decrease when that implant is removed&#46; The determination of metal ions in hair could be a good marker of the metal poisoning that occurs in these arthroplasty models&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tras el implante de algunos modelos de pr&#243;tesis de cadera metal-metal se produce una elevaci&#243;n de los niveles de metales en suero y orina&#46; Recientemente se ha demostrado que hay concordancia entre estas cifras y los niveles encontrados en el cabello&#46; Nuestro objetivo ha sido estudiar la presencia de metales en cabello y conocer si ello se modifica con el paso del tiempo o con la extracci&#243;n del implante&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En 45 pacientes con una artroplastia de superficie se ha realizado una determinaci&#243;n de los niveles de cromo&#44; cobalto y molibdeno en cabello a los 3&#44; 4&#44; 5 y 6 a&#241;os desde el implante&#46; La edad media fue de 57&#44;5 a&#241;os&#44; 2 eran mujeres&#46; En 11 pacientes&#44; en 5 de ellos por metalosis y quiste periarticular&#44; fue necesaria una reintervenci&#243;n para extracci&#243;n de la artroplastia e implante de un nuevo modelo con fricci&#243;n metal-polietileno&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Las cifras medias de metales en cabello fueron cromo 163&#44;27<span class="elsevierStyleHsp" style=""></span>ppm&#44; cobalto 61&#44;98<span class="elsevierStyleHsp" style=""></span>ppm y molibdeno 31&#44;36<span class="elsevierStyleHsp" style=""></span>ppm&#44; muy por encima de los niveles referidos en la poblaci&#243;n general&#46; En los pacientes reintervenidos para extracci&#243;n de la artroplastia se observ&#243; al a&#241;o de la intervenci&#243;n una disminuci&#243;n del 43&#44;8&#37; en los niveles de cromo&#44; del 51&#44;1&#37; en molibdeno y del 90&#44;3&#37; en cobalto&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En las artroplastias de cadera con fricci&#243;n metal-metal se aprecia una alta concentraci&#243;n de metales en el cabello&#44; que disminuye cuando dicho implante es extra&#237;do&#46; La determinaci&#243;n de iones en cabello puede ser un buen marcador de la intoxicaci&#243;n por metales que sucede en estos modelos artropl&#225;sticos&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Hernandez-Vaquero D&#44; Rodr&#237;guez de la Flor M&#44; Fernandez-Carreira JM&#44; Sariego-Mu&#241;iz C&#46; Detecci&#243;n de iones met&#225;licos en cabello tras artroplastia de cadera metal-metal&#46; Rev Esp Cir Ortop Traumatol&#46; 2014&#59;58&#58;267&#8211;273&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1750
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Levels of metals in hair &#40;in ppm&#41; during follow-up at 3 and 6 years&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Levels of metals &#40;in ppm&#41; before and after revision surgery in cases of metallosis&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">95&#37; confidence interval</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Variation coefficient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Minimum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maximum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Lower limit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Upper limit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">163&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">262&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">300&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1616&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Co&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">106&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">618&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">222&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab550217.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Levels of metals in hair &#40;in ppm&#41;&#46;</p>"
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      3 => array:7 [
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Before revision surgery</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">After revision surgery</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cr in hair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">185&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">226&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;70&#8211;683&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">102&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">132&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;00&#8211;396&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;028&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Co in hair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">147&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">233&#46;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;70&#8211;618&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;30&#8211;205&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;249&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mo in hair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;90&#8211;74&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;80&#8211;35&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;043&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab550216.png"
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            0 => array:3 [
              "identificador" => "tblfn0005"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Comparative results following implant extraction &#40;in ppm&#41;&#46;</p>"
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      4 => array:7 [
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        "tabla" => array:1 [
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Goull&#233; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Nowak<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Davies et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Batzevich<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Elenge et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Miekeley et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Ray et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Current series&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Co &#8211; mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cr &#8211; mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">163&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mo &#8211; mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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Article information

ISSN: 19888856
Original language: English

DOI:10.1016/j.recote.2014.06.003

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Year/Month	Html	Pdf	Total

2024 November	2	0	2
2024 October	11	4	15
2024 September	17	7	24
2024 August	18	13	31
2024 July	14	3	17
2024 June	9	2	11
2024 May	10	2	12
2024 April	30	3	33
2024 March	20	3	23
2024 February	10	5	15
2024 January	42	3	45
2023 December	24	3	27
2023 November	21	8	29
2023 October	19	4	23
2023 September	13	3	16
2023 August	10	6	16
2023 July	14	7	21
2023 June	27	0	27
2023 May	25	2	27
2023 April	32	2	34
2023 March	25	1	26
2023 February	9	2	11
2023 January	17	4	21
2022 December	15	2	17
2022 November	12	6	18
2022 October	18	7	25
2022 September	21	12	33
2022 August	18	7	25
2022 July	9	4	13
2022 June	14	4	18
2022 May	12	7	19
2022 April	16	6	22
2022 March	10	6	16
2022 February	8	8	16
2022 January	10	5	15
2021 December	5	5	10
2021 November	9	7	16
2021 October	15	11	26
2021 September	11	8	19
2021 August	8	5	13
2021 July	10	6	16
2021 June	22	7	29
2021 May	20	5	25
2021 April	24	14	38
2021 March	11	12	23
2021 February	10	3	13
2021 January	10	3	13
2020 December	1	0	1
2018 February	2	0	2
2018 January	5	0	5
2017 December	5	0	5
2017 November	4	1	5
2017 October	10	0	10
2017 September	10	1	11
2017 August	15	1	16
2017 July	13	2	15
2017 June	13	1	14
2017 May	11	1	12
2017 April	15	1	16
2017 March	13	1	14
2017 February	7	2	9
2017 January	6	0	6
2016 December	6	8	14
2016 November	3	2	5
2016 October	22	1	23
2016 September	15	7	22
2016 July	0	1	1
2016 May	0	1	1
2016 April	0	1	1
2016 February	0	1	1
2016 January	0	1	1
2015 October	0	1	1
2015 August	0	1	1
2015 May	0	4	4
2015 April	0	1	1
2014 October	1	0	1
2014 September	2	2	4

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