Health Phys.1972;22:359-367. As recently as five years ago, the medical community mostly believed that metallosis derived from metal-on-metal artificial hips. Br Med J. With chronic systemic exposure, cobalt accumulates in tissue, again primarily the liver and kidney, and the cobalt level will be elevated in the serum, whole blood, and urine. J Bone Joint Surg Am. Yet, more importantly, these patients with cobalt alloy-containing metal-on-metal hip prostheses that require revision surgeries due to metallosis have elevated circulating cobalt levels and may be at risk for systemic cobalt toxicity. In the blood, cobalt metal ions bind to albumin with an estimated free fraction of approximately 5 to 12%[6]. 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. What is Arthroplasty Cobalt Encephalopathy (ACE)? J Med Toxicol. This value was not derived from a comparison of symptomatic to asymptomatic patients with cobalt alloy-containing metal-on-metal prostheses, and thus does not serve as a threshold value to evaluate for systemic cobalt toxicity. 09: Signs Your Artificial Hip May Be Defective, Aqueous Film-Forming Foam (AFFF) and Cancer: What You Need to Know, Physical Therapist: Problems with Metal-on-Metal Hip Failures (Part 3), Physical Therapist: What It Feels Like When Artificial Hips Fail (Part 2), Physical Therapist Discusses Hip Replacement Surgery, Recovery (Part 1). 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). ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. There are no established indications for chelation therapy[1]. Toxins include organic solvents (with high blood-brain permeability) and metals (with sometimes poorly understood mechanisms of neural uptake). Acta Orthop. Also, it is well past time for medical device companies to slow down and return to more extensive testing of new medical products. 2013 Nov 22 [Epub ahead of print]. Others suggest that whole blood values provide a more accurate assessment of systemic exposure[1, 6]. Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. Cobalt ions induce chemokine secretion in primary human osteoblasts. Cobalt and chromium can be released as the metal ball grinds against the metal cup when a person walks or moves. 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? Does this settle the questions regarding artificial hip implants and metallosis? Acute exposures are generally characterized by an allergic dermatitis. These devices are made from a blend of several different metals, including chromium, cobalt, nickel, titanium and molybdenum. Of course not. Cobalt poisoning is a common problem in patients with artificial hips. Severe exposures to Cr (VI) compounds are usually accidental or intentional (suicide), and are rarely occupational or environmental. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. 7. Cobalt has also been used as a treatment for anemia, because it stimulates red blood cell production. 2010;92(17):2847-2851. 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. Skin Malady: Exposure to cobalt can occasionally produce dermatitis, but typically hypersensitivity reactions are less commonly associated with cobalt than other metals, such as nickel. 2013 Jul 11 (ahead of print). 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. 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. 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]. Serum concentrations >1 mcg/L indicate possible environmental or occupational exposure, and concentrations >5 mcg/L are considered toxic. J Arthroplasty. 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]. Sci Total Environ. The signs and symptoms of Chromium Toxicity depend on whether the exposure occurred through oral ingestion, chronic inhalation, or skin contact. Tower SS. The contact form sends information by non-encrypted email, which is not secure. These patients presented with combinations of deafness, blindness, cognitive decline, headaches, convulsions, fatigue, heart failure, and hypothyroidism, all had hip pain resulting from periprosthetic metallosis, and all had serum cobalt concentrations of more than 60 �g/L. An individual is exposed to this chemical element via inhalation, ingestion, or dermal exposure and, in general, chronic exposure is required for most of the adverse effects to develop.. Oral intake of Cr (VI) compound may cause 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. Since cobalt has been shown to be carcinogenic and mutagenic in human and animal models, the potential for systemic toxicity and cancer risk are valid safety concerns for patients with these prostheses[4]. 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. Unfortunately, most neurologic symptoms are highly subjective, but some can be proven objectively, including optic nerve atrophy, audiometry-confirmed hearing loss, and abnormal neurologic function illustrated by electrodiagnostic studies such as an electroencephalograms (EEG) or electromyograms (EMG). Cobalt has also been used as a treatment for anemia, because it stimulates red blood cell production. Essentially, they suggest that these patients should be followed carefully and specifically questioned regarding alterations in neurological, cardiac, and endocrine function. Chronic poisoning. 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. The concentration of cobalt, in particular, was remarkably high. Arsenic is a type of carcinogen thatâs gray, silver, or white in color. In these patients, they advise to consider serial cobalt metal ion testing, but also strongly advise interpretation of these levels in the context of the patient's clinical symptoms, baseline renal function, and potential alternative sources of cobalt. Chronic cobalt poisoning may cause polycythemia, hyperplasia of the bone marrow and thyroid gland, pericardial effusion, and damage to the alpha cells of the pancreas. 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