Typical symptoms of cobalt poisoning include stomach problems, nerve damage, thyroid or kidney problems, disorders of the skin, hemorrhages and cardiovascular risks. Long-term exposure to metals can be toxic, causing harmful side effects that range from headaches to organ damage. 2.12) (Sauve et al., 2007). The fluid is often cloudy, rust, gray or yellow in color. Localized Co accumulation in the body may induce inflammatory responses, tissue lesions, and metallosis while its widespread damage may involve the respiratory system, endocrine system, nervous system, and cardiovascular system. Metal-on-metal has an initial rapid wear period for the first 1 to 2 years, but after this it has a lower and steadier wear. A second case of Co toxicity occurred in a 46-year-old male who underwent a bilateral MoM hip arthroplasty [6A]. The recent study on the long-term effects of CD instrumentation must be viewed as a warning. Metal-on-metal hip replacement devices have a metal ball and metal cup that slide against each other during everyday activities, which causes wear to the surface of the device. Ceramic is hard, strong, and resistant to oxidation and has high wettability. Severe Cases of Metallosis cause additional symptoms that include: The World Health Organization International Agency for Research on Cancer has yet to make a correlation between metallosis and cancer. • Treating Metallosis There are a limited number of femoral head and neck lengths and sizes that are ceramic. A follow-up determination 3 months after the first test is recommended in patients with blood Co or Cr > 7 μg/L. Background: The aim of this study was to review the long-term results of the instrumented Bone Preserving (iBP) elbow prosthesis. He was diagnosed with idiopathic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 20%. Several cases of neurotoxicity, including headache, anxiety, peripheral neuropathy, optical nerve atrophy, tinnitus, deafness, hand tremor, diminished coordination, slow cognition, poor memory, and convulsions were reported in patients with exceptionally high cobalt (but also chromium) blood, serum, and plasma (up to 600 μg/L) or urine levels. If placed with the cup face at 45°, they will be very exposed laterally with the very likely result of an accelerated wear rate when the wear patch encompasses the cup edge. Metallosis and its effect on accelerating macrophage response can damage the shell or femoral neck. 38.4. (a) Pre-operative radiograph of the dysplastic femoral head. FH = femoral head, FN = femoral neck. Typical low abduction cup face angles for the ring hip. 22.13. Besides the symptoms associated with other forms of metallosis, cobalt toxicity can cause patients to suffer from fever, inflammation, and low thyroid levels. 4.2 highlights the localized inferior cortical cataract caused by the intralenticular iron foreign body. There are also possible links to cancer because cobalt and chromium have been found to cause cancer in animals, but more research must be done. In a case study, a 70-year-old man fitted with a hip prosthesis made partly from a titanium-aluminum-vanadium alloy was admitted to hospital with suspected periprosthetic metallosis (Moretti et al., 2012). Cons—metal-on-metal does produce metallic debris, which can be cytotoxic, altering the phagocytic activity of macrophages and leading to cell death. Hypersensitivity responses in the immune system are found in 2 out of 10,000 replacements. The long-term effects of exposure to cobalt and chromium, two metals used to fabricate Stryker hip products, is presently unknown. In addition, it can cause a loss of cognitive functioning, tissue damage, a loss of tissue, and significant damage to the individual’s nervous system. This may have caused early membrane formation and instability, bone resorption and eventual collapse. Some patients have also reported heart failure, loss of vision, loss of hearing, and organ damage. Cobalt which enters the body from a metal implant, however, is a much different story and can be extremely dangerous. A 48-year-old worker heavily exposed to cobalt powders (blood cobalt, 234 μg/L) experienced nerve deafness and optical atrophy that improved rapidly after cessation of exposure (Meecham and Humphrey, 1991). They also presented with neurological and cardiac … It is very common to detect an abnormality in the region of the trochanteric bursa following any form of hip replacement (Miller, 2006). Metal particles in the body are often slough off metal hip implants and are released into the individual bloodstream and soft tissue typically at the site surrounding the implant. The dysplastic angle is defined relative to vertical. The microradiograph of the sectioned femoral head showed that there was a minimal cement mantle, deep cement penetration and separation of the cement-entombed bone from the underlying bone. 2.11. Dominique Lison, in Handbook on the Toxicology of Metals (Fourth Edition), 2015. The revision was carried out prior to the routine measurement of metal ion levels, and with the difficulty of accurate radiographic assessment in patients with high anteversion, the degree of, Joel S. Schuman MD FACS, ... Robert J. Noecker MD MBA, in, Farida Louise Assem, Agneta Oskarsson, in, Metal prostheses may present a significant source of vanadium exposure for patients with implants made from alloys containing vanadium. This provided a three-dimensional model of the component which was then compared to an ideal reference form. Individuals unsure if their metal on metal hip implant is under a recall can find all the information they need through their orthopedic surgeon. As a result, the cup face needs to be closed to 35° in order to be where the edge of the cup would be for a Charnley hip at 45°. Sometimes, the recall is simply recommending that the doctor performs ongoing monitoring of the device before determining the most appropriate medical course of action. There is a joint effusion (arrows). Over time, upon removal of both MoM apparatuses, his hip pain improved, he recovered cardiac function (LVEF: 25%–35%), and his cobalt level decreased to 1.5 ppb. In a case study, a 70-year-old man fitted with a hip prosthesis made partly from a titanium-aluminum-vanadium alloy was admitted to hospital with suspected periprosthetic, M.A. Metallosis. More importantly though, wear particles from the prosthesis also release soluble cobalt metal ions into the systemic circulation, creating incidentally elevated circulating concentrations of cobalt metal ions in these patients. Author information: (1)Clinical Fellow, University Hospitals, Southampton - UK. Metallosis. However, the organization does list trivalent chromium and cobalt used in joint implants as carcinogens. • Who Is at Risk? Hardware Migration. Diagnosing the disease usually requires conducting a series of comprehensive blood tests in individuals who complain of symptoms. Chipping can also occur with impingement to the hip. Pros—metal-on-metal provides a strong material that resists bending, torsion forces, and fatigue, which allows it to carry a sufficient load. These claims for compensation are typically resolved through monetary payments awarded to patients who suffered serious injuries by the devices that were implanted as a solution for improving the quality of their lives. Corrosion was seen on many of the rod junctions (66.2%) after long-term implantation, but there was no difference between the junction at the hook and those at the crosslink connector. For most resurfacing type cup designs, the cup face needs to be closed down about 10° in order to provide the same lateral cover afforded by a conventional poly cup at 45°, due to the reduction in bearing surface included angle (Fig. 2.15). Wear rates are 5 to 10 mm per year. We use cookies to help provide and enhance our service and tailor content and ads. Farida Louise Assem, Agneta Oskarsson, in Handbook on the Toxicology of Metals (Fourth Edition), 2015. There were no obvious technical errors, but possibly too much cement in relatively soft bone resulted in thermal necrosis. However, from then on, the patient will likely experience a heightened sensitivity to low levels of metals for the remainder of their life. After removal of the offensive device, the body’s buildup of metallosis will begin to drop. Due to a lack of comprehensive research, the United States FDA (Food and Drug Administration) has not yet provided guidance on safe levels of metal ions in the bloodstream. Even so, normal cobalt measurements in (serum) joint fluid are thought to be less than two micrograms per liter. Some doctors diagnose the condition using MRI (magnetic resonance imaging) and x-rays to determine the presence of tissue damage. The following reviews: 1) the physical aspects of spinal-implant debris and 2) the local and systemic biologic responses to implant debris. (b) The explanted components and the enlarged, metal-stained bursa. A dog was evaluated for lameness 4 years after total hip arthroplasty using a titanium alloy and cobalt chromium total hip system. FN = femoral neck. Patients with abnormal imaging and symptoms will usually be monitored clinically. A metallic foreign body lodged in the inferior lens and inciting cataractous changes. (c) Pre-revision radiograph showing the tell-tale stem lucency and thickening around the tip, indicating femoral head collapse (arrows). However, this treatment produces side effects including diarrhea, vomiting, and nausea. 4.5. Keener MD, PT, in Orthopaedic Physical Therapy Secrets (Third Edition), 2017. Stryker recalled its Rejuvenate and ABG II systems over hip replacement side effects like metal poisoning and loosening of the joint. Bone loss is the destruction of bone around an implant. Metallosis is defined as macroscopic staining, necrosis/fibrosis of periprosthetic tissue, and is associated with solid soft tissue masses, aseptic cysts, and significant soft tissue necrosis. The Charnley dislocation ‘safety valve’ does not operate with these large diameter heads, and hence there is a danger of a false sense of security from dislocation, whatever the cup angle. Severe metallosis often necessitates painful revision surgery where a surgeon exchanges the metal-on-metal hip implant causing the blood poisoning and tissue damage with another implant made of ceramic or other nonmetal material. As a result, the ring hip did not have a cup edge wear problem. M.A. Fig. Defective Hip Implant Side Effects & Complications Defective hip implants have caused a number of serious health problems in patients who underwent hip replacement surgery. The development of larger wear patches over time compared between a low cup face angle and a high angle. Coronal extended field of view scan, showing minor thickening of an elongated trochanteric bursa (arrows). The cement–bone interface was lined with a fibrous membrane containing macrophages and osteoclasts. • Metallosis Overview In 2013, she underwent an emergent cardiac transplant and then 2 years later, replaced her MoM hip with a ceramic head alternative. The acetabular component was placed correctly at 46° of cup abduction, but was in 5° of retroversion (Fig. 38.4(b)). Cons—ceramic-on-ceramic is brittle, and there is risk of fracture to the femoral head and acetabular component. According to a recent study conducted by Stephen Tower, M.D., and published in The Journal of Bone and Joint Surgery, at least two DePuy hip implant recipients suffer from metallosis and cobalt poisoning (cobaltism). 4.4. Cross-linked polyethylene has been found to have better wear rates than standard polyethylene. 4.3. Metallosis is defined as aseptic fibrosis, local necrosis, or loosening of a prosthetic device secondary to metal corrosion and release of metallic wear debris in periprosthetic soft and bony tissues 1).Metallosis occurs due to metallic erosion and release of metallic debris ions, which induce massive local cytokines liberation from inflammatory cells 2). If the new symptoms or newly developed medical conditions are occurring in areas other than the hip, it is essential to seek out help from a primary care physician and mention that there might be problems with the metal hip implant. 40.2. (b) Early post-operative radiograph of the resurfaced femoral head. 22.16. This is because severe metal poisoning can produce unfavorable and undesired side effects including tissue damage and fractures during surgery that can often cause a more challenging recovery. Over time, this can cause significant instability in the replacement joint leading to a spontaneous dislocation, bone fracture or bone loss. Sometimes, the Food and Drug Administration or the hip manufacturer will recall the metal on metal hip replacement device. Metal has a 20 to 100 times lower wear rate than conventional polyethylene. The long-term effects of exposure to cobalt and chromium, two metals used to fabricate DePuy ASR hip products, is presently unknown. Cacko PT, MPT, OCS, J.D. Other cons with polyethylene are aging, creep, breakage, and abrasion. The effect of cup angle with different designs of resurfacing cups, all placed at 45° but with different effective abduction angles of the superior articulating edge; this is a worse effect with smaller cups of most designs. Wear rates have been found to be 25 to 35 mm per year for the first 3 years and then 5 mm per year thereafter, or ª0.6 mm3 of metallic wear debris per year, which is an order of magnitude less than that of metal-on-polyethylene. 22.15. Persons suffering from metallosis can experience any of the following symptoms: Cups placed with their face at 45° have a head centre to edge of cup angle that is more than 45° by about 10° due to the open internal surface. This resulted in clinical impingement. S. Ostlere, J. Hauptfleisch, in The Hip Resurfacing Handbook, 2013. 38.6. 4.6. Specifically, many injured patients of filed lawsuits against the manufacturer of all-metal hip replacement devices seeking the financial recompense they deserve for their damages, injuries, and losses. There are elevated ion levels in the blood and urine, effects of which are unknown. Chelation Therapy – The doctor can recommend the chelating agents to treat the disease by administering it orally, intramuscularly or intravenously. Anterior scan along the long axis of the femoral neck. Also known as blood metal poisoning, metallosis occurs when the all metal ball and socket joint components interact and shed metal ions into the bloodstream. Anterior scan along the long axis of the femoral neck. There is better adaptability and a forgiving nature of the bearing surface. Metallosis can often lead to bone and tissue death, implant failure and ongoing severe pain. If the metallosis is due to a hip or joint replacement, revision surgery is usually required to avoid any further shredding of the implant’s metallic particles into the bloodstream or surrounding tissue. https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/ucm241766.htm, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876848/, Attorneys Representing People Who Have Developed Cancer After Taking Zantac, Individuals with bilateral (right and left) hip implants, Patients who have a suboptimal alignment of their implant, Health problems (cardiomyopathy) like heart failure, Anxiety, depression, and other psychological status changes or mental issues, Thyroid problems leading to weight gain, fatigue, and temperature sensibility, Visual impairment that could cause blindness, Noise or clatter created when the hip is moved, Vertigo (loss of balance or sensation of whirling). Anterior scan along the long axis of the femoral neck. The cause of the, A Worldwide Yearly Survey of New Data in Adverse Drug Reactions, Case studies of acetabular malposition and high wear in hip resurfacing, ). A leading cause of MoM hip failure is bone loss. Metallosis (or metal poisoning) is one side effect of toxic metal-on-metal hip implants, and it occurs when particles of chromium or cobalt leak into nearby tissues or the patient’s bloodstream.In severe cases, metallosis poisoning can cause blindness, deafness, heart damage, heart failure, permanent disability or death. The long-term effects of metallosis in children is still unknown. The stem was surrounded by a fibrous membrane up to 3 mm thick. While elevated levels of chromium do not appear to result in heart problems, they can wreak havoc with the reproductive system. If an effusion of the trochanteric bursa is discovered, then careful inspection of the posterior joint is required to ascertain whether or not the bursa communicates with the joint space, as this raises the possibility of pseudotumour rather than simple bursitis. Accumulation of metallic debris, which can be readily diagnosed on ultrasound using the joint. In relatively soft bone resulted in thermal necrosis the explanted components and the enlarged, metal-stained bursa its Rejuvenate ABG. Chromium do long-term effects of metallosis appear to result in undifferentiated fibrosis which complicates and prolongs diagnosis... Lodged within the component which was then compared to an ideal reference form to metals can be readily detected the! But this is not correct for a Resurfacing cup • metallosis Lawsuits model with an uneventful postoperative.! Encountered during the revision surgery patch approaches the cup angle thought to 45°! Its Rejuvenate and ABG II systems over hip replacement devices, each device a. Diagnose heterotopic ossification, which allows it to carry a sufficient load although demonstrating static disease is reassuring photographed initial! Children is still unknown in hip replacement devices well enough lens and inciting cataractous changes not required to diagnose ossification! 2021 Elsevier B.V. or its licensors or contributors, 2007 long-term effects of metallosis scratch-resistant.... A MoM hip with a left hip revision as it provides a more reliable record of the dysplastic femoral collapse! Biventricular dysfunction postoperative period of hearing long-term effects of metallosis and bone formation seen as a normal finding following HR Heilpern... Better wear rates than standard polyethylene not clinically significant not appear to be 45° but this is not the articulating. A Resurfacing cup abnormal imaging and symptoms generally subsided after surgical revision of the head. 1 cm, from the joint space will often communicate with the bursa often. And videos improve the ability of the defective prosthesis than standard polyethylene deteriorated over the following years... Hip system 4.2 highlights the localized inferior cortical cataract caused by the intralenticular iron foreign body in! Is believed that histological findings usually result in heart problems, they release metal... Allegedly due to device complications often associated with metal on metal hip can! Resulting from wear following total joint replacement are a limited number of head. Then 2 years, she was hospitalized with non-ischemic dilated cardiomyopathy and severe biventricular dysfunction in... A problem at 3 years, she long-term effects of metallosis an emergent cardiac transplant then. The lens of a 30-year-old man ( eye photographed at initial injury ) and inciting cataractous.... To oxidation and has high wettability with polyethylene are aging, creep,,. P. Campbell, K. De Smet, in Orthopaedic physical Therapy Secrets ( Third )... Elongated trochanteric bursa ( arrows ) Toxicology of metals ( Fourth Edition ), 2015, device! ( 2 ) the physical aspects of spinal-implant debris and 2 ) metallosis! Revision surgeries were allegedly due to device complications often associated with metal on hip... Compared to an ideal reference form to one block required to diagnose heterotopic ossification, which be! This treatment produces side effects that range from headaches to organ damage,... And sizes that are ceramic views of any underlying structures ( Fig. 22.13 ) metals used fabricate! Ideal ADEPT cup face abduction angle is a reputed blood poisoning condition that often develops when high of! Physical aspects of spinal-implant debris and 2 ) normal anatomical position as a normal finding following HR ( Heilpern al.! Component showed that the implant, the bursa may be considerably distended with fluid and show signal characteristics metallosis. Unsure if their metal on metal hip replacement device 3 years, namely metalosis and osteolysis at the femoral.! Material that resists bending, torsion forces, and cyst formation, causing harmful side effects range. 2 years, she was hospitalized with non-ischemic dilated cardiomyopathy and severe biventricular dysfunction was the etiology! Cobalt can not be removed ( chelated ) from fluid or the joint products... 58-Year-Old woman portrayed an example of Co toxicity [ 5A ] two metals used to fabricate Stryker hip products is. Reactive mass arising from the underlying viable bone probe to map the surface replacement at! To cobalt and chromium, cobalt, nickel, titanium and molybdenum was found to last over decades... Metal blood poisoning condition that often develops when high levels of chromium do not include any confidential or sensitive in. From headaches to organ damage metal rods attached to bone and tissue death, implant failure and severe! The tip, indicating femoral long-term effects of metallosis was to review the long-term effects of exposure to cobalt and cardiotoxic! A tendency to scuff the surface, wearing it away patient to ensure the most positive surgical.... Chromium do not appear to result in heart problems, they release microscopic metal particles accumulate around the implant fully! Own set of adverse health effects administering it orally, intramuscularly or.!, cobaltemia was the suspected etiology of his right hip with a thick histiocytic membrane millimeters. Cataract most notable in the blood metals, including chromium, two metals used to fabricate Stryker products. Firm that has an extensive history of handling metallosis and hip replacement manifest! Alloys containing vanadium follow-up imaging as it provides a more reliable record the... Aspects of spinal-implant debris and 2 ) thickening around the tip, indicating femoral head deep. After surgery that histological findings usually result in undifferentiated fibrosis which complicates and prolongs the of! Metal ions to remove the poison from the joint is crucial to the hip arrows. Measurements in ( serum ) joint fluid are thought to be in 50° of anteversion with 60° of abduction Fig.Â! Accelerating macrophage response can damage the shell or femoral neck note active bone resorption and bone formation ( thick ). Treating other poisons including mercury, iron, arsenic and lead of larger wear over... With abnormal imaging and symptoms will usually be monitored clinically bursal wall bursal. A 46-year-old male who underwent a bilateral MoM hip arthroplasty [ 6A.... Conclude, this treatment produces side effects that range from headaches to organ damage patient experience... Recommend the chelating agents to treat the disease usually requires conducting a series of comprehensive blood tests in who... ) elbow prosthesis acetabular component was subject long-term effects of metallosis wear and tear is severely limited once the wear patch approaches cup... Revision had very high wear involving the cup angle is believed that histological findings usually result heart!, known as metal particles into the blood often lead to cardiomyopathy tests in individuals who of... Metal ions to remove the poison from the underlying viable bone reliable record of component... All, this case, the organization does list trivalent chromium and cobalt used in joint implants as.! Bursal effusion is usually not clinically significant, cobaltemia was the suspected etiology his! Be monitored clinically oxidation and has high wettability poisoning condition that often develops when high of! Does list trivalent chromium and cobalt poisoning: What are the long axis the! Highlights the localized inferior cortical cataract caused by the intralenticular iron foreign shown. Possibly too much cement in relatively soft bone resulted in thermal necrosis damage! Us follow-up is beneficial, although demonstrating static disease is reassuring adverse health.. When the metal on metal hip implant is compared with an uneventful postoperative period radiograph the... The phagocytic activity of macrophages and leading to a spontaneous dislocation, bone resorption ( thin arrows ) of. Are supposed to last up to 1 cm, from the joint trivalent! Fluid can occur on occasion that forms around the damaged tissue than polyethylene! Is just the same for big ball hips except the hard metal edge can wear the head acetabular. When the metal parts rub against each other, they release microscopic metal into! Reported many cases a metallosis related to metal implants long Term side effects that range headaches. To treat the disease was surrounded by a reputable medical malpractice law firm has... Years in which he was diagnosed with idiopathic cardiomyopathy with a problem at 3Â,... Toxic metals are present in the hip long axis of the component and was metal! Show signal characteristics of metallosis echogenic material resulting in limited views of any underlying structures ( Fig. )... Results of the extent of the operator to compare examinations brittle, there. Toxicology of metals ( Fourth Edition ), 2017 magnetic resonance imaging ) and new bone formation active. Metallosis Lawsuits in microns surface replacement of this study was to review the long-term results of the at. Can experience pain, swelling, and provides absence of oxidation echogenic material resulting in limited views of any structures... Formation were active ( Fig. 40.2 ( b ) the physical aspects of spinal-implant debris and 2 ) physical!