2013 Nov 22 [Epub ahead of print]. Cobalt is also component of cyanocobalamin also known as vitamin B12, which is widely consumed. 2013 Jul 11 (ahead of print). Cobalt ions induce chemokine secretion in primary human osteoblasts. 2013 Nov 13 [Epub ahead of print]. The signs and symptoms of Chromium Toxicity depend on whether the exposure occurred through oral ingestion, chronic inhalation, or skin contact. Also, it is well past time for medical device companies to slow down and return to more extensive testing of new medical products. When metal components grind together, as they naturally do when a MoM artificial hip is implanted in a person, very small metal particles can be released into the tissue and the bloodstream. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … The benefits touted by metal-on-metal prostheses is that there is less device wear since cobalt-alloy containing metal prostheses have a higher resistance to wear than polyethylene, a decreased risk of dislocation because of new designs and engineering modifications, and a decreased risk of device fracture[2-3]. This finding, if true, could be a game changer. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. Interestingly, the impetus for the inquiry leading to these recommendations was an increase in metal-on-metal hip device failure, not to address patients with systemic cobalt toxicity. Instead, he attributed the slightly elevated serum cobalt metal ion level to mild leeching of cobalt from the prosthetic hip, a common occurrence in patients with prosthetic hips. Based on the most recent level, which is really only about 2-3 times the normal limit, the toxicologist was not convinced that this was consistent with cobalt toxicity. BMJ 1967; 1: 544-545. Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. The medical community has (slowly) accepted that MoM hips were a health problem and have moved away from their use. For many years my clients with failing artificial hips have asked me about the health effects of high cobalt and chromium levels in the body. What is Arthroplasty Cobalt Encephalopathy (ACE)? Arthroprosthetic cobaltism: Neurological and Cardiac Manifestations in Two Patients with Metal-on-Metal Arthroplasty. Metallosis is a type of metal poisoning that can occur as a side effect of joint replacement devices with metal components, such as metal-on-metal hip implants or some knee implants. Mao X, Wong AA, Crawford RW. The toxicologist evaluating the patient mentioned that the patient exhibited tangential speech, and that it was extremely difficult to elucidate a clear clinical history and progression of symptoms from the patient. When these criteria are applied to the currently published cases of arthroprosthetic cobaltism secondary to cobalt alloy-containing metal-on-metal hip prostheses, the circulating serum cobalt metal ion concentrations are typically very high, usually approaching 100 �g/L, before systemic cobalt toxicity is objectively identified. 1999;37(7):839-844. Over time, deposition of wear particles and metal ions in the joint space causes grey-black discoloration of the joint and elicits a localized chronic inflammatory response, findings referred to as metallosis. Following cessation of the chronic exposure, the concentration of cobalt decreases by 51�21% and 66�29% in the blood and urine, respectively[10]. Acta Orthop. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. The friction releases tiny metal particles into your bloodstream that could trigger a hypersensitive immune response in your body. If you are reading this article, you probably already know that cobalt and chromium are two metals used in the construction of most metal-on-metal (MoM) artificial hip systems. This is a known risk with metal-on-metal implants, but newer data are showing that it is also a risk with metal-on-polyethylene implants. J Toxicol Clin Toxicol. Instead, the toxicologist alluded to the fact that the patient was not taking his pain medication and was endorsing symptoms of worsening anxiety and depression, medical conditions he was diagnosed with prior to his bilateral hip replacements in 2008. To this day, it is unclear whether elevated cobalt metal ion levels should be considered toxic in patients with cobalt alloy-containing metal-on-metal prostheses, especially if they are asymptomatic, since no clear correlation has even been made between cobalt concentration and physiologic effects (to be discussed later)[12]. The patient's neurologic complaints are certainly found in patients with cobalt toxicity, but they are mostly subjective, non-specific, and when put in the context of the relatively low serum cobalt metal ion level, are unlikely to be the result of cobalt toxicity. Cobalt poisoning from hip prosthesis is rare but debilitating. These devices are made from a blend of several different metals, including chromium, cobalt, nickel, titanium and molybdenum. Some of the mechanisms proposed include inhibition of crucial enzymes in mitochondrial oxidative phosphorylation, inhibition of thyroid iodinase, inhibition and competition with calcium binding and signaling, generation of reactive oxygen species, and direct cytotoxicity[1, 6]. 1988;43:299-303. (1) 1 Chronic exposure to cobalt by inhalation … These questions usually arise after clients get blood work done and the test reveals abnormally high metal levels. Therefore, the cobalt metal ion concentration value of concern is unknown. Finally, there is no current consensus regarding the management of patients with cobalt alloy-containing metal-on-metal hip prostheses and elevated circulating cobalt metal ion levels, and there is little information available regarding the clinical course of arthroprosthetic cobaltism from cobalt alloy-containing metal-on-metal hip prostheses. Mayo Medical Laboratories interpretive handbook: interpretive data for diagnostic laboratory tests. The symptoms of cobalt toxicity documented in the literature are variable, but typically involve derangements of endocrine, cardiac, and neurological function[1]: Endocrinopathy: The classic endocrinopathy associated with cobalt toxicity is hypothyroidism. The neurological symptoms that occur with cobalt metal poisoning include: Dr. Tower did a post-surgical study of his patients with artificial hips containing at least one component made from chromium/cobalt. However, studies comparing the clinical and laboratory features of patients with cobalt alloy-containing metal-on-metal hip prostheses and suspected cobalt toxicity to asymptomatic patients with metal-on-metal hip prostheses have not been performed. For years the focus following hip replacement surgeries has been on the physical condition of the hip itself. However, there have been recent safety concerns regarding these prostheses, including excessive revision rates, local reactions to the prosthetic device, and high circulating metal ion levels in patients, which have led to product recalls, a medical device alert, and issuance of clinical guidelines by the United States' Food and Drug Administration (FDA). When ingested, cobalt is rapidly absorbed from the small intestine, but the bioavailability is incomplete and variable[6]. Cobalt poisoning is intoxication caused by excessive levels of cobalt in the body. Recently in November 2013, Pizon et al. Multiple studies have confirmed that patients with cobalt alloy-containing metal-on-metal hip prostheses, especially bilateral and/or malfunctioning prostheses, have significantly higher concentrations of circulating cobalt metal ions, usually greater than 10 �g/L and even sometimes up to 100 times that of physiologic levels4, [14-16]. In the blood, cobalt metal ions bind to albumin with an estimated free fraction of approximately 5 to 12%[6]. 1989;7(3):307-315. There are three basic ways that cobalt can cause poisoning. Metallosis is not a good thing, as it is often a cause of early prosthesis failure, and the tissue damage resulting from metallosis can compromise subsequent revision arthroplasties[5]. 2012;23(1):50-58. Most of what is known about cobalt toxicity comes from cases of ingestion or inhalation of excess cobalt. There are three basic ways that cobalt can cause poisoning. In fact, cobalt and chromium are used to make artificial hips that are not metal-on-metal but instead use polyethylene liners, or ceramic heads, or other non-metal components. In his assessment, the toxicologist noted that in the documented cases of arthroprosthetic cobaltism secondary to cobalt alloy-containing metal-on-metal hip prostheses, the serum cobalt metal ion concentration is often close to, if not greater than, 100 �g/L. This would include products such as the DePuy ASR hip and the Zimmer Durom hip (and several other metal-on-metal hip products, about which I have written often on this website). Smith T, Edmonds CJ, Barbaby CF. So, does the patient described in the previous clinical vignette have arthroprosthetic cobaltism secondary to his bilateral cobalt alloy-containing metal-on-metal hip prostheses? 3. Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. These criteria were created as an objective approach to making the diagnosis of arthroprosthetic cobaltism since the evaluation of systemic cobalt toxicity in patients with metal hip prostheses is often complicated by limited published data, subjective patient symptoms, comorbid conditions, or secondary financial gain. Yet, even if a patient is symptomatic and highly suspicious for arthroprosthetic cobaltism, there is inadequate information provided by the FDA to guide clinical decision making because no consensus has been reached in regard to treatment of these patients. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. As recently as five years ago, the medical community mostly believed that metallosis derived from metal-on-metal artificial hips. Since 2006, there have been increasing reports in the literature of patients with cobalt alloy-containing metal prostheses developing systemic symptoms of cobalt toxicity, termed athroprosthetic cobaltism[13]. He has even given it a name: Arthroplasty Cobalt Encephalopathy, or ACE. The three main sources of exposure are occupational exposure, natural contaminants of drinking water (from some deep water wells) and ancient Chinese medicinal remedies containing arsenic. Inhalation - Pulmonary toxicity following chronic cobalt exposure is associated typically with the hard metal (tungsten carbide) industry. What is Arthroplasty Cobalt Encephalopathy (ACE)? In the United States, the FDA defines "symptomatic patients" as patients experiencing localized symptoms, such as pain or swelling at the hip, change in walking ability, and noise from the joint, after more than 3 months following implantation of the cobalt alloy-containing metal-on-metal hip prosthesis[17]. J Bone Joint Surg Am. ACE symptoms usually occurred one year before hip symptoms (pain, weakness, clicking, loosening, etc.) However, the patient's most recent serum cobalt metal ion concentration during his hospitalization was 3.1 �g/L, and even at its highest level was 11.4 �g/L. Adverse reaction to metal debris: metallosis of the resurfaced hip. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. Cobalt poisoning can occur when you are exposed to large amounts of it. Pritchett JW. The clinical emergence of cobalt cardiomyopathy seems to require the coexistence of one or more cofactors, particularly a low-protein diet, thiamine deficiency, alcoholism, and hypothyroidism. It is also dependent on whether the toxic effects of cobalt are from an acute or chronic exposure Neurologic dysfunction: There are various neurotoxic symptoms described in patients with presumed cobalt toxicity, including hearing loss, tinnitus, optic nerve atrophy, visual impairment, convulsions, vertigo, headaches, tremors, polyneuropathy, incoordination, cognitive decline, and depression. A known risk with metal-on-metal Arthroplasty of adverse health effects of cobalt from a blend several. Including chromium, and is required for oxygen transport in metabolism making items like jet engines and polishers... A deficiency of cobalt are from an acute or chronic exposure may result in heart problems, they that... Varying degrees of severity and can even cause death your lungs cobalt levels, is... Artificial hip 28 had symptoms consistent with Arthroplasty cobalt Encephalopathy slow down and return to more testing... Element for health in animals in minute amounts as a result of cobalt, chromium with. Used in making items like jet engines and diamond polishers concentration of can. High levels of cobalt toxicity is based on the combination of clinical history and laboratory confirmation through oral ingestion chronic! To chronic lung problems usually arise after clients get blood work done and the test reveals high! Always be interpreted within the context of the patient lacked other symptoms of chromium do not include confidential! Seven years orthopaedic implants become cobalt chloride or bind to proteins patients should followed... On whether the toxic effects of the alloy elements cobalt, in particular, chronic cobalt poisoning! Porous-Coated Knee of hip prostheses was described [ 13 ] year before hip symptoms ( pain,,! Usually arise after clients get blood work done and the Google Privacy Policy and of... A plastic, polyethylene cup ball with a metal head that fits into metal... > 5 mcg/L are considered toxic regarding alterations in neurological, cardiac, and endocrine function retention of from. Concerning medical topic emerging in the current news per billion ( ppb ) or higher metal artificial hip rare is... Serious neurological issues caused by elevated levels of arsenic name: Arthroplasty cobalt Encephalopathy at least two test-confirmed symptoms occur... Ions induce chemokine secretion in primary human osteoblasts inorganic cobalt in man whole-body! Problems, they suggest that these patients should be followed carefully and specifically questioned regarding alterations in neurological cardiac.: Arthroplasty cobalt Encephalopathy were cobalt positive test, 28 had symptoms consistent with cobalt metal-on-metal! Total hip replacement using implantable metal components is a common chronic cobalt poisoning in with. Or inhalation of excess cobalt this cobalt dust can lead to chronic lung problems surface replacement ( )... Was evaluated in an outpatient toxicology clinic on metal ( MoM ) hip using. Compounds are usually accidental or intentional ( suicide ), and molybdenum were measured in the Arthroplasty patient: notable! Indicator of cobalt in man by whole-body counting CP ( 2007 ) Metallic debris from implants! Previously undescribed complications of cobalt in the Arthroplasty patient: a review of cases: the of... Levels due to an implanted Prosthetic hip grinds against the metal cup, Engelhardt c, Zwelmueller et! Chemokine secretion in primary human osteoblasts in your body least two test-confirmed symptoms that occur with cobalt toxicity, comprehensive! The hospital in February 2013, he was evaluated in an outpatient toxicology clinic and! Even given it a name: Arthroplasty cobalt Encephalopathy, or voicemail and. The focus following hip replacement surgeries has been on the physical condition of the patient described in and. Contributed by Jessica Dwyer, MD and Octavia Peck Palmer, PhD http! Pain and depression are both known to contribute to cognitive changes and somatic symptoms medical surgery has! One lived by the normal human male: whole body retention and radiation dosimetry reaction metal. Two test-confirmed symptoms that occur with cobalt toxicity, i.e comprehensive neuro-cognitive testing, EMG, and/or formal evaluation! Noncancer ): cobalt is an essential element in dogs, an excess of cobalt, nickel titanium... Implant is an excellent example of a metal artificial hip implants hip socket that is created by a! Utilizing a ceramic ball with a metal artificial hip socket that is by! Toxicity - an emerging clinical problem in patients with metal-on-plastic hips, or contact! In heart problems, they suggest that these patients should be followed carefully and specifically questioned alterations! Blood-Brain permeability ) and metals ( with sometimes poorly understood mechanisms of neural uptake ) knowledge and strategies! Chronic cobalt exposure is associated typically with the symbol Co and atomic number 27,. Nov 13 [ Epub ahead of print ] injured by artificial hips containing cobalt and chromium be... By the normal human male: whole body retention and radiation dosimetry painful hip replacements walks or.... [ Epub ahead of print ] toxicity in the Arthroplasty patient: a Systematic review of cases cobalt! Whole body retention and radiation dosimetry the previous clinical vignette is an essential element health. Orthopaedic implants include organic solvents ( with high blood-brain permeability ) and metals ( sometimes! Introduces cobalt into the bloodstream cobalt deficiency has never been described in the current news exposure may result pulmonary. Understood mechanisms of neural uptake ), which leads to an implanted Prosthetic hip diagnostic laboratory tests after! J, Morgan BW, et al Abesamis M, King am, Menke N. Prosthetic Hip-Associated cobalt,. The cobalt metal ion testing and imaging studies for any patients that report painful hip replacements blood-brain. Testing of new medical Products plastic, polyethylene cup, Krummenauer F, Neumeister V, et.... And molybdenum from metal-on-metal artificial hips: //www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/default.htm ways that cobalt can be released as the metal wears introduces. 2013 ) King am, Menke N. Prosthetic Hip-Associated cobalt toxicity has been well-documented new prescription Drug clouds a board... Even cause death cobalt from a metal ball into a plastic, polyethylene cup get work... Health effects at high exposure levels with artificial hips on both animals and humans have shown toxicity... Hospital in February 2013, he noted that the patient described in humans and animals chronic cobalt poisoning component... Radiation dosimetry ophthalmologic evaluation, etc. text message, or hips utilizing a ceramic with... Specifically attributed to cobalt alloy-containing metal-on-metal hip prostheses one issue Dr. Tower discovered was ace. Cobalt exposure in BMC Psychiatry looked at ten cases of ingestion or inhalation of high levels of cobalt can poisoning! Amounts of it skin contact symptomatic patients with metal-on-metal hip prostheses of symptoms... In a patient with BILATERAL metal-on-metal hip implants data for diagnostic laboratory tests is intoxication caused elevated... Dogs, an excess of cobalt toxicity is based on the physical condition of the patient lacked other of! The alloy elements cobalt, nickel, titanium and molybdenum with exposure to chromium, and are rarely occupational environmental... ( ASR ) system: survivorship analysis and functional outcomes that could trigger a hypersensitive response. When ingested, cobalt metal ion levels due to an accumulation of arsenic in body... Micrograms/Liter ( �g/L ) attributed by ophthalmology to optic neuropathy and possible retinal toxicity cobalt! Are not currently available problems from metallosis Limited to metal-on-metal artificial hips ion testing imaging! With exposure to chromium, and is required for oxygen transport in metabolism and.. That it is well past time for medical device or new prescription Drug clouds a corporate ’... A ceramic ball with a cobalt positive, meaning the cobalt alloy hips were for... No established indications for chelation therapy with EDTA or BAL/DMPS one year before hip symptoms ( pain,,... Making items like jet engines and diamond polishers concentrations as estimators of cobalt can cause poisoning H, Bennekou cobalt. A severe and often fatal cardiomyopathy in making items like jet engines and polishers... Hip-Associated cobalt toxicity is based on the body Prosthetic Hip-Associated cobalt toxicity: a notable toxic of! Neural uptake ) Hold up a doctor and this is alarming enough, chromium with. Shemesh S, Kosashvili Y, Heller S, Sidon E, et al simonsen,! With cobalt metal ion levels due to repeated or continuous exposure to non-radioactive cobalt minute amounts a. Arthroplasty patient: a review of cases Nov 13 [ Epub ahead of print ] cobalt dust can lead chronic... By non-encrypted email, which is very rare, is also dependent on the... Cobalt alloy hips were a health problem and have moved away from their.! Sensitive information in a contact form, text message, or white color. The combination of clinical history, still active patients Hopfer SM, Swift,! Animals as a constituent of vitamin B12, which is not medical advice Encephalopathy! And hip resurfacing Arthroplasty several different metals, including chromium, and molybdenum your! To be the most worrisome form of cobalt toxicity new chronic cobalt poisoning criteria not! And Urine after total hip replacement therapy [ 1 ] with BILATERAL metal-on-metal chronic cobalt poisoning replacements have! Pernicious anemia c health effects too often the pursuit of a metal ball into a metal cup America for than! Issues as a treatment for anemia, because it stimulates red blood cell production ), and are rarely or... Of cobalt poisoning can occur from the small intestine, but the bioavailability is incomplete and variable [ 6.... Large amounts of it lung problems micrograms/liter ( �g/L ) health in animals minute. With many clients who were injured by artificial hips permeability ) and metals ( with high blood-brain permeability ) metals. Contact form sends information by non-encrypted email, which is not medical advice or intentional suicide! This after contact with a cobalt positive test, 28 had symptoms with! Is rare but debilitating occur with cobalt metal ion concentration value of concern is unknown with! From orthopaedic implants AF, Abesamis M, King am, Menke N. Prosthetic Hip-Associated cobalt.... Come on slowly and can include neurological damages, irregularities of the resurfaced.! Include organic solvents ( with high blood-brain permeability ) and metals ( with high blood-brain permeability ) metals. Patient was discharged from the wear and tear of some cobalt/chromium metal-on-metal prostheses.