Implantation of titanium alloys (Ti-6Al-4V) or cobalt-chromium-molybdenum alloys (Co-Cr-Mo) for long-segment spinal fixation is the standard surgical treatment for adolescent idiopathic scoliosis (AIS), but long-term presence of the implants in the body may lead to the release of metal nanoparticles. Unlike orthopaedic internal fixation surgeries, spinal implants generally remain in the human body for a lifetime. The release of metal nanoparticles remains a potential clinical issue, but currently there is a lack of strong data on the topic. This study aimed to fill this crucial knowledge gap by providing longitudinal evidence on the dynamics of metal ion release. This is the first step in determining safety characteristics and clinical thresholds. (1) Are serum Ti, Co, and Cr concentrations in patients with AIS after implantation elevated compared with in patients without implantation over a 4-year period? (2) Does surgical removal of implants lead to a reduction in systemic metal nanoparticle load? (3) Is there a correlation between metal ion levels and implant burden? (4) Does implant type (Ti-6Al-4V versus Co-Cr-Mo) influence serum metal concentrations? This was a single-center retrospective cohort study performed at an urban tertiary referral hospital from January 2018 to December 2020. A total of 336 patients with AIS were included, including 60% (201 of 336) who underwent surgical treatment and 40% (135 of 336) who received nonsurgical treatment. Among the 201 patients who underwent AIS operations, 6% (13 of 201) were excluded because of the presence of metal implants in other parts (ulna and radius [n = 5], around the elbow joint [n = 4], femoral shaft [n = 4]), and 15% (31 of 201) were excluded because they were lost to follow-up, resulting in incomplete clinical data. Forty-eight percent (96 of 201) of the patients only received spinal implant treatment without revision surgery (implant group), 23% (46 of 201) of the patients received spinal implant treatment and underwent revision surgery but did not have the implants removed (revision group), and 7% (15 of 201) of the patients received spinal implant treatment, underwent revision surgery, and had the implants removed (removal group). Among the 135 patients with AIS who did not undergo surgery, 6% (8 of 135) were excluded because of the presence of metal implants in other parts (ulna and radius [n = 3], around the elbow joint [n = 3], femoral shaft [n = 2]), and 16% (22 of 135) were excluded because they were lost to follow-up, resulting in incomplete clinical data. Seventy-eight percent (105 of 135) of the patients who did not undergo surgery who met the inclusion criteria were ultimately included in the control group. Since 2015, according to a standardized protocol, serum samples from patients undergoing surgery for AIS and from the nonsurgical control group have been collected. This is part of a broader and ongoing research project for patients with AIS. Between February and April 2025, we determined the metal ion concentrations in the collected blood samples. Serum Ti, Co, and Cr levels were measured via inductively coupled plasma mass spectrometry at multiple postoperative time points. The correlation between metal ion levels and rod length as well as the number of screws were evaluated using correlation analysis. Linear regression analysis was employed to assess the relationship between implant types (Ti-6Al-4V and Co-Cr-Mo), rod diameter, and serum metal concentrations. The extracted implants were subjected to scanning electron microscopy (SEM) combined with energy-dispersive x-ray spectroscopy analysis to examine the surface morphology and elemental composition of the implants. Serum concentrations of Ti, Co, and Cr were higher in patients with spinal implants than in nonsurgical controls at all postoperative time points. At 48 months, the mean ± SD serum Ti was 1.1 ± 0.3 μg/L in the implant group versus 0.2 ± 0.1 μg/L in controls (mean difference 0.9 μg/L [95% confidence interval (95% CI) 0.8 to 1.0]; p < 0.001), for Co it was 0.3 ± 0.2 μg/L versus 0.2 ± 0.1 μg/L (mean difference 0.1 μg/L [95% CI 0.1 to 0.2]; p < 0.001), and for Cr it was 1.0 ± 0.5 μg/L versus 0.1 ± 0.1 μg/L (mean difference 0.9 μg/L [95% CI 0.6 to 0.7]; p < 0.001). Metal levels peaked at 12 months postoperatively and remained elevated for 48 months. Implant removal was associated with a reduction in serum metal concentrations. At 6 months after removal, Ti levels decreased by 1.8 μg/L (95% CI -2.1 to -1.6; p < 0.001), Co levels by 0.4 μg/L (95% CI -0.5 to -0.3; p < 0.001), and Cr levels by 1.2 μg/L (95% CI -1.4 to -1.0; p < 0.001) compared with the removal group. At 12 months after removal surgery, there was no difference in Ti ion concentration between the removal group and the control group (0.2 ± 0.2 versus 0.2 ± 0.1, mean difference 0.0 [95% CI -0.2 to 0.1]; p = 0.38). Similarly, no difference was observed in Co ion concentration (0.2 ± 0.1 versus 0.2 ± 0.1, mean difference 0.0 [95% CI -0.1 to 0.1]; p = 0.62). Additionally, Cr ion concentration did not differ between groups (0.2 ± 0.1 versus 0.1 ± 0.1, mean difference 0.1 [95% CI -0.2 to 0.1]; p = 0.45). Serum metal concentrations correlated positively with implant load (rod length r = 0.85 to 0.87, number of screws r = 0.87 to 0.88; all p < 0.001) and rod diameter (β = 0.54 to 0.58; all p < 0.001).The serum Co concentration had a substantial positive correlation with the use of Co-Cr-Mo implants (β = 0.54; p < 0.001). Similarly, the serum Cr concentration had a substantial positive correlation with the use of Co-Cr-Mo implants (β = 0.58; p < 0.001). SEM analysis confirmed implant surface corrosion and nanoscale defects consistent with metal release. Serum levels of Ti, Co, and Cr increase after posterior spinal fusion in patients with AIS, reaching a peak at 12 months after operation, and remaining elevated for at least 4 years, which suggests continuous release of metal ions from the implants. Removal of the implants was associated with a reduction in serum metal ion levels, confirming that the implants are the main source of metal nanoparticle release. The concentration of metal ions is related to the burden of the implant (such as the length of the rod and the number of screws) and the type of implant. However, the clinical importance of elevated metal ions needs further confirmation. Our findings are preliminary and do not support routine metal ion tests or imaging examinations in patients with AIS treated surgically or recommendations regarding implant removal; however, future research may attempt to correlate ion levels with symptoms or imaging results in the study environment. Level III, therapeutic study.