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Ajibo DN, Orish CN, Ruggieri F, Bocca B, Battistini B, Frazzoli C, Orish FC, Orisakwe OE. An Update Overview on Mechanistic Data and Biomarker Levels in Cobalt and Chromium-Induced Neurodegenerative Diseases. Biol Trace Elem Res 2024; 202:3538-3564. [PMID: 38017235 DOI: 10.1007/s12011-023-03965-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/12/2023] [Indexed: 11/30/2023]
Abstract
There is increasing evidence that the imbalance of metals as cobalt (Co) and chromium (Cr) may increase the risk of development and progression of neurodegenerative diseases (NDDs). The human exposure to Co and Cr is derived mostly from industry, orthopedic implants, and polluted environments. Neurological effects of Co and Cr include memory deficit, olfactory dysfunction, spatial disorientation, motor neuron disease, and brain cancer. Mechanisms of Co and Cr neurotoxicity included DNA damage and genomic instability, epigenetic changes, mitochondrial disturbance, lipid peroxidation, oxidative stress, inflammation, and apoptosis. This paper seeks to overview the Co and Cr sources, the mechanisms by which these metals induce NDDs, and their levels in fluids of the general population and patients affected by NDDs. To this end, evidence of Co and Cr unbalance in the human body, mechanistic data, and neurological symptoms were collected using in vivo mammalian studies and human samples.
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Affiliation(s)
- Doris Nnena Ajibo
- Department of Experimental Pharmacology & Toxicology, Faculty of Pharmacy, University of Port Harcourt, PMB, 5323, Port Harcourt, Rivers State, Nigeria
| | - Chinna Nneka Orish
- Department of Anatomy, College of Health Sciences University of Port Harcourt, PMB, 5323, Port Harcourt, Rivers State, Nigeria
| | - Flavia Ruggieri
- Department of Environment and Health, Istituto Superiore Di Sanità, Rome, Italy
| | - Beatrice Bocca
- Department of Environment and Health, Istituto Superiore Di Sanità, Rome, Italy
| | - Beatrice Battistini
- Department of Environment and Health, Istituto Superiore Di Sanità, Rome, Italy
| | - Chiara Frazzoli
- Department for Cardiovascular, Endocrine-Metabolic Diseases, and Aging, Istituto Superiore Di Sanità, Rome Viale Regina Elena, 29900161, Rome, Italy
| | | | - Orish E Orisakwe
- Department of Experimental Pharmacology & Toxicology, Faculty of Pharmacy, University of Port Harcourt, PMB, 5323, Port Harcourt, Rivers State, Nigeria.
- African Centre of Excellence for Public Health and Toxicological Research (ACE-PUTOR), University of Port Harcourt, PMB, 5323, Port Harcourt, Rivers State, Nigeria.
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Floyd CA, Carr JR, Brock L, Orvin DL. Enteral N-acetylcysteine to reduce serum cobalt concentrations secondary to prosthetic knee-associated metallosis: A case report. Am J Health Syst Pharm 2024; 81:e159-e165. [PMID: 38141216 DOI: 10.1093/ajhp/zxad312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Indexed: 12/25/2023] Open
Abstract
PURPOSE Cobalt metallosis is a rare but dangerous complication of total joint arthroplasty resulting from deterioration of the joint leading to metal-on-metal friction and breakdown. Potential manifestations vary in severity and include dilated cardiomyopathy, thyroid dysfunction, cognitive disturbances, neuropathy, fatigue, and weakness. The therapeutic role of N-acetylcysteine in metallosis has been investigated due to its ability to chelate with heavy metal ions, such as cobalt and chromium. SUMMARY Here we report the case of a 71-year-old female who presented with suspected metallosis diagnosed in the outpatient setting due to symptoms of significant weight loss and failure to thrive. This metallosis was secondary to the hardware breakdown of a left knee revision roughly 6 years previously. The patient was not a surgical candidate due to her poor nutrition status and was started on nasojejunal tube feeds along with N-acetylcysteine 600 mg by mouth twice daily for 45 days. The patient's serum cobalt levels decreased from 61.7 µg/L on admission to 16.2 µg/L prior to her undergoing proper revision of the left knee roughly 2 months after admission to the hospital. The patient tolerated treatment well and was able to be discharged the day after surgery, with no further complaints or complications. CONCLUSION This case report contributes to the body of literature suggesting that administration of N-acetylcysteine can reduce serum cobalt concentrations, without notable adverse effects, in the context of prosthetic knee-associated metallosis.
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Affiliation(s)
| | - John R Carr
- St. Joseph's/Candler Health System, Savannah, GA, USA
| | - Logan Brock
- University of Georgia College of Pharmacy, Athens, GA, USA
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Revision total hip arthroplasty by a ceramic bearing surface after a third- and fourth-generation ceramic head or liner fracture. INTERNATIONAL ORTHOPAEDICS 2023; 47:1197-1202. [PMID: 36808282 DOI: 10.1007/s00264-023-05705-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/16/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE Although rare, fractures of ceramic components are difficult to revise, mainly due to the presence of residual ceramic debris that can cause catastrophic wear of the replacement components. Modern ceramic-on-ceramic bearings are suggested to improve outcomes of revision total hip arthroplasty (THA) for ceramic fractures. However, there are few published reports of mid-term outcomes of revision THA using ceramic-on-ceramic bearings. We evaluated clinical and radiographic outcomes of 10 patients who received ceramic-on-ceramic bearings during revision THA for ceramic fractures. METHODS All patients but one received fourth-generation Biolox Delta bearings. Clinical evaluation was performed using the Harris hip score at latest follow-up, and all patients received a radiographic evaluation to analyze the fixation of the acetabular cup and of the femoral stem. Osteolytic lesions and the presence of ceramic debris were noted. RESULTS After a mean follow-up of 8.0 years, there were no complications or implant failures, and all patients reported satisfaction with their implant. The average Harris hip score was 90.6. There was neither osteolysis nor loosening, but despite our extensive synovial debridement, ceramic debris was noted in the radiographs of five patients (50%). CONCLUSION We report excellent mid-term outcomes, with no implant failures after eight years despite ceramic debris being found in a significant proportion of patients. We conclude that modern ceramic-on-ceramic bearings are an advantageous option for the revision of THA due to the fracture of initial ceramic components.
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Abdel Hamid OI, Attia ME, Hirshon JM, El-Shinawi M, El-Hussaini M, El-Setouhy M. Psychiatric Disorders and Genotoxicity Following Primary Metal on Polyethylene Total Hip Arthroplasty and Their Correlation to Cobalt/Chromium Levels. Drug Healthc Patient Saf 2022; 14:97-111. [PMID: 35880007 PMCID: PMC9308046 DOI: 10.2147/dhps.s360643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Hip arthroplasty (HA) using implantable metal components is among the commonest orthopedic interventions. However, it can be followed by several complications following corrosion and the release of metal ions. Several studies proved that damaged genomic DNA may contribute to the pathophysiology of mental disorders. Aim The current work aims to evaluate the psychiatric disorders in metal on polyethylene hip arthroplasty (MOP-HA) patients and its correlation to cobalt/chromium (Co/Cr) levels and genotoxicity. Methods The work was a longitudinal follow-up study including 34 adults with unilateral primary MOP-HA meeting the inclusion and exclusion criteria. Preoperatively, 6, 12-months-postoperatively, patients were examined for cognitive impairment using mini-mental-state-examination (MMSE), depression using major-depressive-inventory (MDI), and blood samples were collected for estimation of Co/Cr, detection of genotoxicity by single-cell-gel-electrophoresis (comet assay) and serum 8-hydroxy-2'-deoxyguanosine (8-OHdG). Results Cognitive impairment was reported in 18.5% and 14.8% at 6-months, and 12-months postoperative, respectively. Depressive disorder was recorded in 22.2% at 6-months and 14.8% at 12-months postoperative. The marginal homogeneity tests proved a non-significant difference. There was a non-significant difference in preoperative, 6-months, 12-months postoperative MMSE, and MDI scores. There were significantly increased Co/Cr levels at 6-months postoperative. The levels decreased at 12-months postoperative, however, still significantly higher than preoperative values. There was a significant increase in serum 8-OHdG and the levels were positively correlated to cobalt levels at both 6 and 12-months-postoperative. There was a non-significant difference among preoperative, 6-months, and 12-months postoperative comet assay measurements. Conclusion From previous findings, we can conclude that will-functioning MOP hip arthroplasty can induce increased ion levels and positively correlated increase in biochemical markers of genotoxicity (8-OHdG).
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Affiliation(s)
- Omaima I Abdel Hamid
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed E Attia
- Orthopedics Departments, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Jon M Hirshon
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, MD, USA
- Department of Epidemiology and Public Health, University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Mohamed El-Shinawi
- Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Galala University, Galala City, Suez, Egypt
| | - Moustafa El-Hussaini
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Maged El-Setouhy
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Department of Family and Community Medicine, Faculty of Medince, Jazan University, Jazan, Kingdom of Saudi Arabia
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Crutsen JRW, Koper MC, Jelsma J, Heymans M, Heyligers IC, Grimm B, Mathijssen NMC, Schotanus MGM. Prosthetic hip-associated cobalt toxicity: a systematic review of case series and case reports. EFORT Open Rev 2022; 7:188-199. [PMID: 35298414 PMCID: PMC8965198 DOI: 10.1530/eor-21-0098] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Prosthetic hip-associated cobalt toxicity (PHACT) is caused by elevated blood cobalt concentrations after hip arthroplasty. The aim of this study is to determine which symptoms are reported most frequently and in what type of bearing. We also try to determine the blood level of cobalt concentrations associated with toxicological symptoms. A systematic review was conducted on the 10th of July according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A methodological quality assessment (risk of bias (RoB)) was performed. Primary outcomes were the reported symptoms of cobalt toxicity and the level of cobalt concentrations in blood. These levels were associated with toxicological symptoms. A total of 7645 references were found of which 67 relevant reports describing 79 patients. The two most used bearings in which PHACT was described were metal-on-metal (MoM) bearings (38 cases) and revised (fractured) ceramic-on-ceramic (CoC) bearings where the former ceramic head was replaced by a metal head (32 cases). Of all reported symptoms, most were seen in the neurological system, of which 24% were in the sensory system and 19.3% were in central/peripheral system, followed by the cardiovascular (22.1%) system. The mean cobalt concentration for MoM-bearings was 123.7 ± 96.8 ppb and 1078.2 ± 1267.5 ppb for the revised fractured CoC-bearings. We recommend not to use a metal-based articulation in the revision of a fractured CoC bearing and suggest close follow-up with yearly blood cobalt concentration controls in patients with a MoM bearing or a revised fractured CoC bearing. Level of Evidence: Level V, systematic review.
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Affiliation(s)
- J R W Crutsen
- Department of Orthopaedic Surgery, VieCuri Medical Center, Venlo, the Netherlands
| | - M C Koper
- Department of Orthopaedic Surgery, Reinier HAGA Orthopaedic Center, Zoetermeer, the Netherlands
| | - J Jelsma
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, the Netherlands
| | - M Heymans
- Zuyderland Academy, Centre of Knowledge and Information (KIC), Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| | - I C Heyligers
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, the Netherlands
- School of Health Professions Education (SHE), Maastricht University, Maastricht, the Netherlands
| | - B Grimm
- Luxembourg Institute Health, Human Motion, Orthopaedics, Sports Medicine, Digital Methods (HOSD), Luxembourg, Luxembourg
| | - N M C Mathijssen
- Department of Orthopaedic Surgery, Reinier HAGA Orthopaedic Center, Zoetermeer, the Netherlands
| | - M G M Schotanus
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, the Netherlands
- School of Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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Jenkinson MRJ, Meek RMD, Tate R, MacMillan S, Grant MH, Currie S. Cobalt-induced cardiomyopathy - do circulating cobalt levels matter? Bone Joint Res 2021; 10:340-347. [PMID: 34053230 PMCID: PMC8242681 DOI: 10.1302/2046-3758.106.bjr-2020-0414.r2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Elevated levels of circulating cobalt ions have been linked with a wide range of systemic complications including neurological, endocrine, and cardiovascular symptoms. Case reports of patients with elevated blood cobalt ions have described significant cardiovascular complications including cardiomyopathy. However, correlation between the actual level of circulating cobalt and extent of cardiovascular injury has not previously been performed. This review examines evidence from the literature for a link between elevated blood cobalt levels secondary to metal-on-metal (MoM) hip arthroplasties and cardiomyopathy. Correlation between low, moderate, and high blood cobalt with cardiovascular complications has been considered. Elevated blood cobalt at levels over 250 µg/l have been shown to be a risk factor for developing systemic complications and published case reports document cardiomyopathy, cardiac transplantation, and death in patients with severely elevated blood cobalt ions. However, it is not clear that there is a hard cut-off value and cardiac dysfunction may occur at lower levels. Clinical and laboratory research has found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. Further work needs to be done to clarify the link between severely elevated blood cobalt ions and cardiomyopathy. Cite this article: Bone Joint Res 2021;10(6):340–347.
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Affiliation(s)
| | | | - Rothwell Tate
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | | | - M Helen Grant
- Biomedical Engineering, University of Strathclyde, Glasgow, UK
| | - Susan Currie
- Biomedical Engineering, University of Strathclyde, Glasgow, UK
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Yu CH, Chiang PY, Yeh YC. Di(2-picolyl)amine-functionalized poly(ethylene glycol) hydrogels with tailorable metal–ligand coordination crosslinking. Polym Chem 2021. [DOI: 10.1039/d1py01325d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A new class of metallo-hydrogels has been developed using di(2-picolyl)amine (DPA)-functionalized 4-arm polyethylene glycol (4A-PEG-DPAn) polymers crosslinked by metal–ligand coordination.
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Affiliation(s)
- Cheng-Hsuan Yu
- Institute of Polymer Science and Engineering, National Taiwan University, Taipei, Taiwan
| | - Pei-Yu Chiang
- Institute of Polymer Science and Engineering, National Taiwan University, Taipei, Taiwan
| | - Yi-Cheun Yeh
- Institute of Polymer Science and Engineering, National Taiwan University, Taipei, Taiwan
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8
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Bridges RL, Cho CS, Beck MR, Gessner BD, Tower SS. F-18 FDG PET brain imaging in symptomatic arthroprosthetic cobaltism. Eur J Nucl Med Mol Imaging 2020; 47:1961-1970. [PMID: 31863138 PMCID: PMC7299907 DOI: 10.1007/s00259-019-04648-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 12/05/2019] [Indexed: 10/28/2022]
Abstract
PURPOSE Imaging studies of cobalt toxicity from cobalt-chromium alloy arthroprosthetics have focused on the local intra-articular and peri-articular presentation from failing joint replacements. Most studies investigating neurological findings have been small case series focused on the clinical findings of memory loss, diminished executive function, tremor, hearing and vision loss, depression, and emotional lability. This study utilizes software-based quantitative analysis of brain metabolism to assess the degree of hypometabolism and areas of susceptibility, determine if a pattern of involvement exists, and measure reversibility of findings after prosthetic revision to cobalt-free appliances. METHODS Over 48 months, 247 consecutive patients presenting to an orthopedic clinic with an arthroprosthetic joint containing any cobalt-chromium part were screened with whole blood and urine cobalt levels. A clinically validated inventory of 10 symptoms was obtained. Symptomatic patients with a blood cobalt level above 0.4 mcg/L or urine cobalt greater than 1 mcg/L underwent F-18 FDG PET brain imaging. Analysis was performed with FDA-approved quantitative brain analysis software with the pons as the reference region. Control group was the normal brain atlas within the software. RESULTS Of the 247 consecutively screened patients, 123 had blood and urine cobalt levels above the threshold. The 69 scanned patients had statistically significant regional hypometabolism and higher symptoms inventory. Fifty-seven patients were retained in the study. Distribution of hypometabolism was in descending order: temporal, frontal, Broca's areas, anterior cingulate, parietal, posterior cingulate, visual, sensorimotor, thalamic, and lastly caudate. Metal-on-metal (MoM) and metal-on-plastic (MoP) joint replacements produced similar patterns of hypometabolism. Of 15 patients with necessary revision surgery, 8 demonstrated improved metabolism when later re-scanned. CONCLUSION All scanned patients had regions of significant hypometabolism. Neurological toxicity from elevated systemic cobalt levels following arthroprosthetic joint replacement has a pattern of regional susceptibility similar to heavy metals and solvents, differing from classical dementias and may occur at blood and urine cobalt levels as low as 0.4 mcg/L and 1 mcg/L, respectively. Presently accepted thresholds for cobalt exposure and monitoring may need revision. Quantitative F-18 FDG PET brain imaging may aid in the decision process for treatment options and timing of possible medical versus surgical intervention.
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Affiliation(s)
- Robert L Bridges
- Aegis Imaging Consultants, LLC, P.O. Box 751, 170 Cervin Circle, Girdwood, AK, 99587, USA.
| | - Christina S Cho
- Aegis Imaging Consultants, LLC, P.O. Box 751, 170 Cervin Circle, Girdwood, AK, 99587, USA
- Tower Joint Replacement Clinic, Inc., Anchorage, AK, USA
| | - Marc R Beck
- Aegis Imaging Consultants, LLC, P.O. Box 751, 170 Cervin Circle, Girdwood, AK, 99587, USA
- Turnagain Radiology Associates, LLC, Anchorage, AK, USA
| | - Bradford D Gessner
- Aegis Imaging Consultants, LLC, P.O. Box 751, 170 Cervin Circle, Girdwood, AK, 99587, USA
- EpiVac Consulting Services, Anchorage, AK, USA
| | - Stephen S Tower
- Aegis Imaging Consultants, LLC, P.O. Box 751, 170 Cervin Circle, Girdwood, AK, 99587, USA
- Tower Joint Replacement Clinic, Inc., Anchorage, AK, USA
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Garcia MD, Hur M, Chen JJ, Bhatti MT. Cobalt toxic optic neuropathy and retinopathy: Case report and review of the literature. Am J Ophthalmol Case Rep 2020; 17:100606. [PMID: 32025592 PMCID: PMC6997813 DOI: 10.1016/j.ajoc.2020.100606] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/29/2019] [Accepted: 01/03/2020] [Indexed: 01/19/2023] Open
Abstract
Purpose We detail a case of cobalt toxicity with visual and systemic complications, review the pathogenic process for the optic neuropathy and retinopathy, and discuss the controversy of metallic hip prosthesis. Observations A 59-year-old female with a history of multiple left hip arthroplasties presented to our clinic with bilateral visual loss. The year prior, she had failure of the hip implant necessitating revision surgery with placement of a chrome-cobalt head. A few months after surgery, she began experiencing blurred and “white, spotty” vision in both eyes in addition to hypothyroidism, cardiomyopathy and neuropathy. The possibility of the patient's symptoms being due to cobalt toxicity from her hip prosthesis was proposed and she was found to have a serum cobalt level >1000 μg/L (normal 0–0.9 ng/mL). Visual acuity was 20/600 in the right and 20/800 in the left eye. There was bilateral temporal optic disc pallor. Goldmann visual field testing demonstrated bilateral central scotomas, optical coherence tomography (OCT) showed severe ganglion cell layer-inner plexiform layer (GCLIPL) thinning and multifocal electroretinography (mfERG) demonstrated decreased amplitudes in both eyes. She underwent a total hip revision arthroplasty with extensive debridement of “black sludge” found within a pseudocapsule. Four days after surgery, cobalt serum levels had significantly decreased to 378 ng/mL. One month after surgery, she had significant improvement in visual acuity (20/150 right eye, 20/250 left eye), Goldmann visual field testing, and mfERG. OCT showed retinal nerve fiber thinning and persistent GCLIPL thinning in both eyes. Conclusions and Importance Excessive cobalt levels can result in systemic toxicity leading to visual changes, peripheral neuropathy, hearing loss, cognitive deficits, cardiomyopathy and hypothyroidism. In recent years it has become apparent that cobalt toxicity can be associated with metal-on-metal total hip arthroplasty, or the grinding effects of retained ceramic particles from a fractured ceramic head on a cobalt-chromium femoral head prosthesis.
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Affiliation(s)
- Maria D Garcia
- Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Minjun Hur
- Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - John J Chen
- Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN, USA.,Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - M Tariq Bhatti
- Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN, USA.,Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Saini R, Railton P, Boyd J, Sadrzadeh H, Powell JN. Concordance between laboratories in metal ion testing in patients with metal-on-metal hip implants. Can J Surg 2019; 62:9-13. [PMID: 30265641 DOI: 10.1503/cjs.015717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Testing of whole blood or serum metal ion levels has become an important part of assessing and monitoring the performance of metal-on-metal bearings, both in hip resurfacing arthroplasty and in total hip replacement. The aim of this study was to determine the concordance between 2 laboratories testing cobalt and chromium ion levels in patients with metal-on-metal bearings. METHODS Serum and whole blood samples from patients who had undergone metal-on-metal resurfacing or large-diameter total hip arthroplasty were tested for cobalt and chromium ions in laboratory A (a recognized laboratory) and laboratory B (tasked with testing clinical specimens). Laboratory A performed cobalt and chromium testing on whole blood, and laboratory B performed cobalt testing on whole blood and chromium testing on serum. RESULTS Samples from 104 patients were tested. Laboratory B reported lower whole blood cobalt levels than laboratory A. Furthermore, laboratory A reported that all patients had elevated whole blood cobalt ion levels compared to the normal reference values for the laboratory, whereas laboratory B reported that 46 patients (44.2%) had whole blood cobalt ion levels within the normal reference range for the laboratory. CONCLUSION This comparative study highlights the importance of using a single laboratory for metal ion testing, as values generated from different laboratories may not be directly comparable. With recent literature suggesting that whole blood cobalt levels as low as 1 ppb may be a predictor of adverse reactions to metal debris, accurate clinical measurement needs to be increasingly exact.
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Affiliation(s)
- Raghav Saini
- From the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Powell, Saini, Boyd, Railton); and Calgary Laboratory Services, Calgary, Alta. (Sadrzadeh)
| | - Pam Railton
- From the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Powell, Saini, Boyd, Railton); and Calgary Laboratory Services, Calgary, Alta. (Sadrzadeh)
| | - Jessica Boyd
- From the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Powell, Saini, Boyd, Railton); and Calgary Laboratory Services, Calgary, Alta. (Sadrzadeh)
| | - Hossein Sadrzadeh
- From the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Powell, Saini, Boyd, Railton); and Calgary Laboratory Services, Calgary, Alta. (Sadrzadeh)
| | - James N Powell
- From the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Powell, Saini, Boyd, Railton); and Calgary Laboratory Services, Calgary, Alta. (Sadrzadeh)
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Gautam D, Pande A, Malhotra R. Fatal Cobalt Cardiomyopathy Following Revision Total Hip Arthroplasty - A Brief Report with Review of Literature. THE ARCHIVES OF BONE AND JOINT SURGERY 2019; 7:379-383. [PMID: 31448317 PMCID: PMC6686060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 06/09/2018] [Indexed: 06/10/2023]
Abstract
Ceramic bearing surfaces are being increasingly used in young patients undergoing total hip arthroplasty. However, failures have been reported including fractures even with the newer third generation ceramics. The recommended treatment for fracture of ceramic bearing surfaces is complete synovectomy and revision total hip arthroplasty. However, disappointing results have also been reported with this approach. The residual ceramic particles may lead to complications. We report a fatal case of cobalt toxicity leading to cardiomyopathy secondary to the catastrophic failure of a Cobalt-Chrome femoral head, which followed the revision of a fractured ceramic-on-ceramic total hip arthroplasty.
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Affiliation(s)
- Deepak Gautam
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
- Department of Orthopedics, Military Hospital, Kirkee, Pune, India
- Research performed at All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Pande
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
- Department of Orthopedics, Military Hospital, Kirkee, Pune, India
- Research performed at All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
- Department of Orthopedics, Military Hospital, Kirkee, Pune, India
- Research performed at All India Institute of Medical Sciences, New Delhi, India
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12
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Revision total hip arthroplasty with metal on metal bearing for ceramic bearing fractures. J Orthop Sci 2019; 24:452-457. [PMID: 30415823 DOI: 10.1016/j.jos.2018.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 09/28/2018] [Accepted: 10/11/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Due to concern of potential metallosis caused by residual microscopic ceramic particles, metal-on-metal (MoM) bearing is deemed undesirable in revision total hip arthroplasty (THA) for ceramic bearing fracture. We determined whether MoM bearing is suitable to be used in revision THA for ceramic fractures and also evaluated whether this treatment increases serum iron levels compared with MoM bearing revision THA for polyethylene failure. METHODS Between 2006 and 2012, 22 patients underwent revision surgery using MoM bearing (28 mm femoral head in 18 hips and 32 mm in 4 hips) for ceramic bearing fracture and followed average 52.1 months. We assessed radiological parameter and functional outcome using Harris hip score (HHS) and WOMAC score. Also, serum cobalt (Co) and chromium (Cr) blood tests were performed and compared with the result obtained from age, sex- and follow-up duration-matched patients with MoM revision THA for failed polyethylene bearing. RESULTS The mean HHS improved from 60.6 preoperatively to 90.3 at final follow-up. There were no changes in cup position, progression of osteolytic lesions, and measurable wear of MoM bearing articulation at final follow-up radiographs. There was one case of recurrent dislocation after surgery, which was treated with greater trochanter distal advancement and one case of deep infection, which underwent two-stage revision. Mean serum Co level (1.7 vs. 1.4 μg/dl; p = 0.211) and Cr level (0.70 vs. 1.01 μg/dl; p = 0.327) showed no significant difference. CONCLUSIONS MoM articulation with liner cementation into the acetabular cup along with total synovectomy can be chosen in revision surgery for ceramic fracture with good midterm follow-up. However, the use of MoM bearing is indicated when the stem and metal shell can be retained and ceramic on ceramic or ceramic on polyethylene bearing cannot be selected. Also long-term outcome needs to be further evaluated.
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Chromium-Cobalt Intoxication with Intense Systemic Complications following Total Hip Revision after Per-Operative Ceramic Fracture. Case Rep Orthop 2019; 2019:4209796. [PMID: 30809405 PMCID: PMC6369479 DOI: 10.1155/2019/4209796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/23/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Heavy metal intoxication after arthroplasty is extremely rare but could be lethal. Case Report. We report the case of a 69-year-old woman, who presented intense systemic symptoms of chromium-cobalt intoxication after revision of per-operative fractured ceramic components with metal-on-polyethylene. Systemic toxicity occurred a year after surgery and expressed brutally with mostly central neurological symptoms. Chelation associated with revision surgery allowed rapid regression of all symptoms. Conclusion Revision of fractured ceramic, even per-operatively, should not be done with metal-on-polyethylene components, in order to avoid potentially lethal metal intoxication.
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Winston BA, Kagan RP, Huff TW. Delayed diagnosis of catastrophic ceramic liner failure with resultant pelvic discontinuity and massive metallosis. Arthroplast Today 2016; 3:77-82. [PMID: 28695178 PMCID: PMC5485230 DOI: 10.1016/j.artd.2016.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/04/2016] [Accepted: 11/09/2016] [Indexed: 12/28/2022] Open
Abstract
With newer-generation ceramic components used in total hip arthroplasty, component fracture is a rare complication. However rare, when ceramic component fracture does occur, prompt identification and revision is necessary as delay can lead to dramatic failure with resultant metallosis as the extremely hard ceramic debris abrades remaining components. We present a case of a 70-year-old woman with ceramic liner fracture and an estimated 10-year delay in intervention with failure resulting in pelvic discontinuity and massive metallosis with associated cutaneous manifestation. She was treated with a complex revision and reconstruction and is 2 years postrevision without major complication.
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Affiliation(s)
- Benjamin A Winston
- Department of Orthopedics and Rehabilitation, The Oregon Health Science University, Portland, OR, USA
| | - Ryland P Kagan
- Department of Orthopedics and Rehabilitation, The Oregon Health Science University, Portland, OR, USA
| | - Thomas W Huff
- Department of Orthopedics and Rehabilitation, The Oregon Health Science University, Portland, OR, USA
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