Arthroprosthetic Cobaltism: Neurological and Cardiac Manifestations in Two Patients with Metal-on-Metal Arthroplasty

Tower, Stephen S.

doi:10.2106/jbjs.j.00125

Cited by 254 publications

(172 citation statements)

References 9 publications

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“…However, their routine use is currently discouraged as a result of concerns regarding elevated serum metal ions and their local [3-5, 8, 13, 19, 20, 25] and systemic side effects [2,10,12,15,18,23,26].…”

Section: Introductionmentioning

confidence: 99%

What Is the Natural History of Asymptomatic Pseudotumors in Metal-on-metal THAs at Mid-term Followup?

Konan

Duncan

Masri

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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Background The risk of early revision because of pseudotumors in patients who have undergone large-head metal-on-metal (MoM) total hip arthroplasty (THA) is well documented. However, the natural history of asymptomatic pseudotumors or of MoM articulations without pseudotumors is less well understood. The aim of our study was to investigate the natural history of primary MoM THA at mid-term followup. Questions/purposes The purposes of this study were: (1) Did previously detected pseudotumors persist or worsen in asymptomatic patients at mid-term followup; and if so, did any of them require revision THA? (2) Did new pseudotumors form in asymptomatic patients at mid-term followup? (3) What happened to serum trace metal ions at mid-term followup? (4) Were postoperative patient-reported outcome measures (PROMs) maintained at midterm followup? Methods Seventy-one patients who underwent a MoM THA using a Metasul LDH implant with a Durom acetabular cup and an M/L Taper stem between September 2005 and October 2008 were reviewed. All patients for this study were part of two previously published studies from our early followup. Data from the previous studies were used for comparison only. Two of the 71 patients (2.8%) were lost to followup. The mean age at operation was 56 years (range, 34-68 years). There were 24 female patients. All patients had serum trace metal ions testing, ultrasound imaging, and PROMs at a mean 3.5 years (early followup) after the index operation (range, 3-5 years) and delayed followup at a mean 7 years (range, 6.5-9 years). The indication to undertake revision THA was based on clinical evaluation and not solely on the investigation results. Results Twenty-three of 71 patients (32%) had a positive ultrasound scan for pseudotumor at early followup. Of these, eight patients underwent revision THA (11% of MoM THA or 35% of patients with an early positive ultrasound scan). The mean time between positive ultrasound scan and revision surgery was 13 months (range, 5-22 months). Of the remaining 15 patients with pseudotumor noted on early ultrasound, 12 had persistent pseudotumor, two resolved, and one was lost to followup. Six patients (13%) with a normal ultrasound scan at early followup showed new ultrasound findings at delayed followup. Of these, four (8%) were conclusively diagnosed as pseudotumor and one was revised. Serum trace metal ion increased at mid-term followup in the seven cases that showed an increase in volume of pseudotumor. Of the five patients in whom the volume of pseudotumor decreased on ultrasound at mid-term followup, three showed a decrease Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the pub...

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Section: Introductionmentioning

confidence: 99%

What Is the Natural History of Asymptomatic Pseudotumors in Metal-on-metal THAs at Mid-term Followup?

Konan

Duncan

Masri

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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“…The patient, diagnosed with PHACT and cardiomyopathy, improved symptomatically with concomitant ejection fraction increase from 21 to 45 % after hardware removal [13]. Similarly, Tower reported subjective improvement in exercise tolerance, dyspnea, and diastolic dysfunction 11 months after hardware removal [9]. Oldenberg et al did not specifically comment on cardiac symptom resolution in the sole biopsyproven case of cardiomyopathy identified in our review [6].…”

Section: Natural Course Of Suspected Phactmentioning

confidence: 71%

“…Recently, safety concerns-excessive revision rates, local reactions, and high metal ion levels-have resulted in product recalls, a medical device alert, and issuance of clinical guidance by the Food and Drug Administration (FDA) in the USA [1][2][3][4]. During the past 6 years, cases of systemic symptoms associated with cobalt-containing metal alloy hip prosthetics (Co-HP) have been reported [5][6][7][8][9][10][11][12][13]. A definitive causal link between Co-HP and systemic symptoms, as opposed to local reactions, has not been definitively established.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2013

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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.

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“…While there has been concern about the carcinogenicity of cobalt and chromium debris, several recent studies show no causal relationship between MOM implants and risk of cancer [14]. However, several reports have shown systemic symptoms of cobalt toxicity including neurologic, renal, and cardiac impairment in patients with high metal ion levels secondary to MOM hip arthroplasties [15].…”

Section: Introductionmentioning

confidence: 99%

Diagnosis of adverse local tissue reactions following metal-on-metal hip arthroplasty

Chalmers

Perry

Taunton

et al. 2016

Curr Rev Musculoskelet Med

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Arthroprosthetic Cobaltism: Neurological and Cardiac Manifestations in Two Patients with Metal-on-Metal Arthroplasty

Cited by 254 publications

References 9 publications

What Is the Natural History of Asymptomatic Pseudotumors in Metal-on-metal THAs at Mid-term Followup?

What Is the Natural History of Asymptomatic Pseudotumors in Metal-on-metal THAs at Mid-term Followup?

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

Diagnosis of adverse local tissue reactions following metal-on-metal hip arthroplasty

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