European Spine Journal

, Volume 23, Issue 11, pp 2393–2400 | Cite as

Serum titanium, niobium and aluminium levels two years following instrumented spinal fusion in children: does implant surface area predict serum metal ion levels?

  • Thomas P. Cundy
  • William J. Cundy
  • Georgia Antoniou
  • Leanne M. Sutherland
  • Brian J. C. Freeman
  • Peter J. CundyEmail author
Original Article



Measurement of serum metal ion levels is used to determine systemic exposure to implant-derived metal debris that may be generated by processes of wear and corrosion. The aim of this study is to investigate predictors of serum metal ion levels in children undergoing instrumented spinal arthrodesis using a titanium alloy, focusing on implant characteristics and instrumentation construct design variables.


This prospective longitudinal cohort study involved 33 children. Serum samples were obtained pre-operatively and at five defined interval periods over the first two post-operative years. Samples were analysed using high-resolution inductively coupled plasma mass spectrometry to measure titanium, niobium and aluminium concentrations. Instrumentation characteristics were catalogued and construct surface area (SA) measurements calculated using an implant-specific software algorithm tool.


Significantly elevated levels of serum titanium and niobium were observed (p < 0.0001), with >95 % of post-operative levels abnormally elevated. Significant predictors of serum titanium and niobium levels included time since surgery, surgical procedure (posterior or anterior fusion), number of levels fused, number of pedicle screws inserted, total rod length, total metal SA, total exposed metal SA and total metal-on-metal SA. All significant instrumentation variables were highly correlated.


There is a strong relationship between implant SA and both serum titanium and niobium levels. The direct clinical implications of these findings for patients are uncertain, but remain of concern. Surgeons should be aware of the strong correlation between implant surface area of the chosen construct and the subsequent serum metal ion levels.


Spinal deformity Paediatric Metal Wear Corrosion Titanium Niobium 



Non-commercial funds were received for this study from the Bone Growth Foundation Inc, Women’s and Children’s Hospital Foundation and Florey Medical Research Fund. The authors wish to acknowledge the contribution of Dr. Peter Kalt (Department of Mechanical Engineering, The University of Adelaide, South Australia) and assistance of Dr. Peter Baghurst, Mrs Susan Barlow RN, Mrs Helena Penny RN, and the staff of SA Pathology Laboratory at the Women’s and Children’s Hospital.

Conflict of interest



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Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Thomas P. Cundy
    • 1
  • William J. Cundy
    • 1
  • Georgia Antoniou
    • 1
  • Leanne M. Sutherland
    • 1
  • Brian J. C. Freeman
    • 1
    • 2
    • 3
  • Peter J. Cundy
    • 1
    • 3
    Email author
  1. 1.Department of Orthopaedic SurgeryWomen’s and Children’s Hospital (WCH)North AdelaideAustralia
  2. 2.Department of Spinal SurgeryRoyal Adelaide HospitalAdelaideAustralia
  3. 3.Discipline of Orthopaedics and TraumaUniversity of AdelaideAdelaideAustralia

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