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Journal of Medical Toxicology

, Volume 9, Issue 4, pp 405–415 | Cite as

Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: a Systematic Review of Cases

  • John J. DevlinEmail author
  • Adam C. Pomerleau
  • Jeffrey Brent
  • Brent W. Morgan
  • Scott Deitchman
  • Michael Schwartz
Review Article

Abstract

Safety concerns regarding cobalt-containing metal alloy hip prosthetics (Co-HP) have resulted in product recalls, a medical device alert, and issuance of guidance for clinicians. Recently, cases of suspected prosthetic hip-associated cobalt toxicity (PHACT) from Co-HP have been reported. Although little is known about suspected PHACT, these patients may be referred to medical toxicologists for evaluation and management recommendations. We searched MEDLINE, EMBASE, and unpublished abstracts from toxicology scientific meetings for references relevant to PHACT. Authors independently screened publications for inclusion criteria: publication in English, human study population, subject(s) are symptomatic (except for isolated hip pain), and cobalt values in any matrix (blood, serum, urine, CSF, synovial fluid) available for review. Data from 10 cases are reviewed. Patients with suspected PHACT had findings consistent with cobalt toxicity, including thyroid, cardiac, and neurologic dysfunction. Signs and symptoms appeared between 3 and 72 months after arthroplasty (median 19 months). Neurologic symptoms were most common. Ancillary testing varied considerably. All patients had elevated cobalt levels in one or more matrices. Enhanced elimination was attempted in 27 % of patients. At this time, the information currently available regarding patients with suspected PHACT is inadequate to guide clinical decision making. No consensus has been reached regarding the management of Co-HP patients with systemic symptoms. Indications for chelation have not been established and require further study. Improved case definitions, improved surveillance, and controlled studies are needed to elucidate the scope of this problem and guide future investigations.

Keywords

Cobalt Poisoning Hip prosthesis Arthroplasty Cobalt toxicity 

Notes

Conflict of Interest

The authors report no declarations of interest. The opinions in this Review are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry. Dr. Brent reports that he has provided background scientific research as a paid consultant for DePuy Companies.

References

  1. 1.
    The United Kingdom Medicines and Healthcare Products Regulatory Agency (2012) Medical device alert: metal-on-metal (MoM) total hip replacements. Ref: MDA/2012/016. Issued 02 April 2012. http://mhra.gov.uk/publications/safetywarnings/ medicaldevicealerts/CON79157. Accessed 11 July 2012
  2. 2.
    The United States Food and Drug Administration (2013) Information for orthopaedic surgeons. Released January 17, 2013. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/ucm241667.htm#3a. Accessed 17 Jan 2013
  3. 3.
    The United States Food and Drug Administration (2013) Information on soft tissue imaging and metal ion testing. Released January 17, 2013. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/ucm331971.htm#metal. Accessed 17 Jan 2013
  4. 4.
    The United States Food and Drug Administration (2013) Information for all health care professionals who provide treatment to patients with a metal-on-metal hip implant. Released January 17, 2013. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/ucm241744.htm. Accessed 17 Jan 2013
  5. 5.
    Steens W, Von Foerster G, Katzer A (2006) Severe cobalt poisoning with loss of sight after ceramic-metal pairing in a hip—a case report. Acta Orthop 77(5):830–832PubMedCrossRefGoogle Scholar
  6. 6.
    Oldenburg M, Wegner R, Baur X (2009) Severe cobalt intoxication due to prosthesis wear in repeated total hip arthroplasty. J Arthroplast 24(5):e15–e20CrossRefGoogle Scholar
  7. 7.
    Rizzetti MC, Liberini P, Zarattini G, Catalani S, Pazzaglia U, Apostoli P, Padovani A (2009) Loss of sight and sound. Could it be the hip? Lancet 373(9668):1052PubMedCrossRefGoogle Scholar
  8. 8.
    Ikeda T, Takahasi K, Kabata T, Sakagoshi D, Tomita K, Yamada M (2010) Polyneuropathy caused by cobalt–chromium metallosis after total hip replacement. Muscle Nerve 42:140–143PubMedCrossRefGoogle Scholar
  9. 9.
    Tower SS (2010) Arthroprosthetic cobaltism: neurological and cardiac manifestations in two patients with metal-on-metal arthroplasty: a case report. J Bone Joint Surg 92(17):2847–2851PubMedCrossRefGoogle Scholar
  10. 10.
    Mao X, Wong AA, Crawford RW (2011) Cobalt toxicity—an emerging clinical problem in patients with metal-on-metal hip prostheses? Med J Aust 194(12):649–651PubMedGoogle Scholar
  11. 11.
    Pazzaglia UE, Apostoli P, Congiu T, Catalani S, Marchese M, Zarattini G (2011) Cobalt, chromium, and molybdenum ion kinetics in the human body: data gained from a total hip replacement with massive third body wear of the head and neuropathy by cobalt intoxication. Arch Orthop Trauma Surg 131:1299–1308PubMedCrossRefGoogle Scholar
  12. 12.
    Pelclova D, Sklensky M, Janicek P, Lach K (2012) Severe cobalt intoxication following hip replacement revision: clinical features and outcome. Clin Toxicol 50:262–265CrossRefGoogle Scholar
  13. 13.
    Machado C, Appelbe A, Wood R (2012) Arthroprosthetic cobaltism and cardiomyopathy. Heart Lung Circ 21(11):759–760PubMedCrossRefGoogle Scholar
  14. 14.
    Loke YK, Price D, Herxheimer A (2007) Systematic reviews of adverse effects: framework for a structured approach. BMC Med Res Method 7(32):1–9Google Scholar
  15. 15.
    Lantin AC, Mallants A, Vereulen J, Speybroeck N, Hoet P, Lison D (2011) Absence of adverse effect on thyroid function and red blood cells in a population of workers exposed to cobalt compounds. Toxicol Lett 201(1):42–46PubMedCrossRefGoogle Scholar
  16. 16.
    Kriss JP, Carnes WH, Gross RT (1955) Hypothyroidism and thyroid hyperplasia in patients treated with cobalt. JAMA 157(2):117–121CrossRefGoogle Scholar
  17. 17.
    Christensen JM, Poulsen OM (1994) A 1982–1992 surveillance programme on Danish pottery painters. Biological levels and health effects following exposure to soluble or insoluble cobalt compounds in cobalt dyes. Sci Total Environ 150(1–3):95–104PubMedCrossRefGoogle Scholar
  18. 18.
    Morin Y, Daniel P (1967) Quebec beer-drinkers' cardiomyopathy: etiological considerations. Can Med Assoc J 97:926–928PubMedGoogle Scholar
  19. 19.
    McDermott PH, Delaney RL, Egan JD, Sullivan JF (1966) Myocardosis and cardiac failure in men. JAMA 198(3):163–166CrossRefGoogle Scholar
  20. 20.
    Linna A, Oksa P, Groundstroem K, Halkosaari M, Palmroos P, Huikko S, Uitti J (2004) Exposure to cobalt in the production of cobalt and cobalt compounds and its effect on the heart. Occup Environ Med 61:877–885PubMedCrossRefGoogle Scholar
  21. 21.
    Baborik M, Dusek J (1972) Cardiomyopathy accompanying industrial cobalt exposure. Br Heart J 34(1):113–116CrossRefGoogle Scholar
  22. 22.
    Jarvis JQ, Hammond E, Meier R, Robinson C (1992) Cobalt cardiomyopathy: a report of two cases from mineral assay laboratories and a review of the literature. J Occup Med 34(6):620–626PubMedGoogle Scholar
  23. 23.
    Kennedy A, Dornan JD, King R (1981) Fatal myocardial disease associated with industrial exposure to cobalt. Lancet 1(8217):412–414PubMedCrossRefGoogle Scholar
  24. 24.
    Bowie EA, Hurley PJ (1975) Cobalt chloride in the treatment of refractory anaemia in patients undergoing long-term hemodialysis. Aust NZ J Med 5:306–314CrossRefGoogle Scholar
  25. 25.
    Licht A, Oliver M, Rachmilewitz EA (1972) Optic atrophy following treatment with cobalt chloride in a patient with pancytopenia and hypercellular marrow. Isr J Med Sci 8:61–66PubMedGoogle Scholar
  26. 26.
    Schirrmacher UOE (1967) Case of cobalt poisoning. Br Med J 1:544–545PubMedCrossRefGoogle Scholar
  27. 27.
    Catalani S, Rizzetti MC, Padovani A, Apostoli P (2011) Neurotoxicity of cobalt. Hum Exp Toxicol 1:1–17Google Scholar
  28. 28.
    Barceloux DG (1999) Cobalt. Clin Toxicol 37(2):201–216CrossRefGoogle Scholar
  29. 29.
    Seghizzi P, D'Adda F, Borleri D, Barbic F, Mosconi (1994) Cobalt myocardiopathy. A critical review of literature. Sci Total Environ 150:105–109PubMedCrossRefGoogle Scholar
  30. 30.
    Holly RG (1955) Studies on iron and cobalt metabolism. JAMA 158(15):1349–1352CrossRefGoogle Scholar
  31. 31.
    Evans EM, Freeman MAR, Miller AJ, Vernon-Roberts BV (1974) Metal sensitivity as a cause of bone necrosis and loosening of the prosthesis in total joint replacement. J Bone Joint Surg 56(4):626–642Google Scholar
  32. 32.
    Jones DA, Lucas HK, O'Driscoll M, Price CHG, Wibberly B (1975) Cobalt toxicity after McKee hip arthroplasty. J Bone Joint Surg 57(3):289–296Google Scholar
  33. 33.
    Polyzois I, Nikolopoulos D, Michos I, Patsouris E, Theocharis S (2012) Local and systemic toxicity of nanoscale debris particles in total hip arthroplasty. J App Toxicol 32:255–26940CrossRefGoogle Scholar
  34. 34.
    Alexanderssen R (1988) Blood and urinary concentrations as estimators of cobalt exposure. Acrh Environ Health 43(4):29–303Google Scholar
  35. 35.
    Devitt BM, Queally JM, Vioreanu M, Butler JS, Murray D, Doran P, O'Byrne JM (2010) Cobalt ions induce chemokine secretion in a variety of systemic cell lines. Acta Orthop 81(6):756–764PubMedCrossRefGoogle Scholar
  36. 36.
    Simonsen LO, Harbak H, Bennejou P (2012) Cobalt metabolism and toxicology—a brief update. Sci Total Environ 432:210–215PubMedCrossRefGoogle Scholar
  37. 37.
    Howie DW, Rogers SD, McGee MA, Haynes DDR (1996) Biological effects of cobalt chrome in cell and animal models. Clin Orthop Relat Res 329s:s217–s232CrossRefGoogle Scholar
  38. 38.
    Kwon Y, Xia Z, Glyn-Jones S, Beard D, Gill HS, Murray DW (2009) Dose-dependent cytotoxicity of clinically relevant cobalt nanoparticles and ions on macrophages in vitro. Biomed Mater 4:1–8CrossRefGoogle Scholar
  39. 39.
    Hallab N, Merritt K, Jacobs J (2001) Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg 83(3):428–436PubMedCrossRefGoogle Scholar
  40. 40.
    Witzleb WC, Ziegler J, Krummenauer F, Neumeiste V, Guenther KP (2006) Exposure to chromium, cobalt and molybdenum from metal-on-metal total hip replacement and hip resurfacing arthroplasty. Acta Orthop 77(5):697–705PubMedCrossRefGoogle Scholar
  41. 41.
    Macnair RD, Wynn-Jones H, Wimhurst JA, Toms A, Cahir J (2012) Metal ion levels not sufficient as a screening measure for adverse reactions in metal-on-metal hip arthroplasties. J Arthroplasty 28(1):78–83PubMedCrossRefGoogle Scholar
  42. 42.
    Smolders JMH, Bisseling P, Hol A, Van Der Straeten C, Schreurs BW, van Susante JLC (2011) Metal ion interpretation in resurfacing versus conventional hip arthroplasty and in whole blood versus serum. How should we interpret metal ion data? Hip Int 21(5):587–595PubMedCrossRefGoogle Scholar
  43. 43.
    Kwon Y, Ostlere SJ, McLardy-Smith P, Athanasou NA, Gill HS, Murray DW (2011) “Asymptomatic” pseudotumors after metal-on-metal hip resurfacing arthroplasty. J Arthroplasty 26(4):511–518PubMedCrossRefGoogle Scholar
  44. 44.
    Alexandersson R (1988) Blood and urinary concentrations as estimators of cobalt exposure. Arch Environ Health 43(4):299–303PubMedCrossRefGoogle Scholar
  45. 45.
    Learmonth ID, Case CP (2007) Metallic debris from orthopaedic implants. Lancet 369:542–544PubMedCrossRefGoogle Scholar
  46. 46.
    Leavelle DE (2001) Mayo Medical Laboratories. Mayo Medical Laboratories interpretive handbook: interpretive data for diagnostic laboratory tests. The Laboratories, Rochester, MNGoogle Scholar
  47. 47.
    Barry J, Lavigne M, Vendittoli PA (2013) Evaluation of the method for analyzing chromium, cobalt, titanium ion levels in the blood following hip replacement with metal-on-metal prosthesis. J Anal Toxicol 37(2):90–96PubMedCrossRefGoogle Scholar
  48. 48.
    Harrington CF, Taylor A (2012) UK quality assurance of blood cobalt and chromium after hip implants. BMJ 344:e4017PubMedCrossRefGoogle Scholar
  49. 49.
    Sampson B, Hart A (2012) Clinical usefulness of blood metal measurements to assess the failure of metal-on-metal hip implants. Ann Clin Biochem 49:118–131PubMedCrossRefGoogle Scholar
  50. 50.
    Llobet JM, Domingo JL, Corbella J (1988) Comparative effects of repeated parenteral administration of several chelators on the distribution and excretion of cobalt. Res Commun Chem Pathol Pharmacol 60(2):225–233PubMedGoogle Scholar
  51. 51.
    Cory-Slechta DA, Weiss B, Cox C (1987) Mobilization and redistribution of lead over the course of calcium disodium ethylenediamine tetraacetate chelation therapy. J Pharmacol Exp Ther 243(3):804–813PubMedGoogle Scholar
  52. 52.
    Oxman AD (1994) Systematic reviews: checklists for review articles. BMJ 309:648–651PubMedCrossRefGoogle Scholar
  53. 53.
    Murphy CM (2012) Writing an effective review article. J Med Toxicol 8:89–90PubMedCrossRefGoogle Scholar

Copyright information

© American College of Medical Toxicology (outside the USA) 2013

Authors and Affiliations

  • John J. Devlin
    • 1
    • 2
    • 3
    Email author
  • Adam C. Pomerleau
    • 1
    • 2
    • 3
  • Jeffrey Brent
    • 4
  • Brent W. Morgan
    • 1
    • 2
  • Scott Deitchman
    • 3
  • Michael Schwartz
    • 1
    • 3
  1. 1.Georgia Poison CenterAtlantaUSA
  2. 2.Department of Emergency MedicineEmory University School of MedicineAtlantaUSA
  3. 3.National Center for Environmental Health (NCEH)Centers for Disease Control and Prevention (CDC)ChambleeUSA
  4. 4.Department of MedicineUniversity of Colorado School of MedicineAuroraUSA

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