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


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 We searched MEDLINE, EMBASE, and unpublished abstracts from toxicology scientific meetings for references relevant to PHACT.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.


Cobalt Poisoning Hip prosthesis Arthroplasty Cobalt toxicity 


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.


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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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