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

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 We searched MEDLINE, EMBASE, and unpublished abstracts from toxicology scientific meetings for references relevant to PHACT.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

The risk of cardiac failure following metal-on-metal hip arthroplasty

“…33 More recently, case reports and small series have reported cardiomyopathy related to failure of MoM implants. 7,[35][36][37][38][39] However, there were < 30 cases in total and these patients had extreme levels of circulating metal ions. Prentice et al 40 performed a cross-sectional observational study of systemic complications and found a 5% lower ejection fraction in 35 patients with MoM resurfacing implants compared with patients with conventional arthroplasties.…”

“…The failure of these devices has led to many patients subsequently undergoing early revision. [5][6][7][8] Corrosion and wear of MoM implants, which are composed of cobalt-chromium alloy, can result in the release of particulate debris and metal ions into the circulation. Alongside localized effects, MoM prostheses have been associated with systemic complications such as cardiotoxicity and mortality.…”

Neuropsychiatric symptoms following metal-on-metal implant failure with cobalt and chromium toxicity

“…Some papers report the physical effects of metallosis following MoM implants [2, 10, 11, 14, 24, 28, 29]. To the best of our knowledge there are no papers specifically describing psychiatric symptoms following MoM implants, but there is a case report indicating neurological problems associated with cobalt and chromium toxicity [27].…”

Outcomes Are Superior in Patients With Acute Stroke From New Zealand Versus Rest of World: Data From the Efficacy of Nitric Oxide in Stroke (Enos) Trial

“…Prior to this research there have been only case reports on people with MoM prostheses who have developed heart failure [4]. The results have implications for people who have received ASR XL prostheses and potentially also other LH MoM prostheses.…”