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

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Abstract

Safety concerns regarding cobalt-containing metal alloy hip prosthetics (Co-HP) have resulted in product recalls, a medical device alert, and issuance of guidance for clinicians. Recently, cases of suspected prosthetic hip-associated cobalt toxicity (PHACT) from Co-HP have been reported. Although little is known about suspected PHACT, these patients may be referred to medical toxicologists for evaluation and management recommendations. We searched MEDLINE, EMBASE, and unpublished abstracts from toxicology scientific meetings for references relevant to PHACT. Authors independently screened publications for inclusion criteria: publication in English, human study population, subject(s) are symptomatic (except for isolated hip pain), and cobalt values in any matrix (blood, serum, urine, CSF, synovial fluid) available for review. Data from 10 cases are reviewed. Patients with suspected PHACT had findings consistent with cobalt toxicity, including thyroid, cardiac, and neurologic dysfunction. Signs and symptoms appeared between 3 and 72 months after arthroplasty (median 19 months). Neurologic symptoms were most common. Ancillary testing varied considerably. All patients had elevated cobalt levels in one or more matrices. Enhanced elimination was attempted in 27 % of patients. At this time, the information currently available regarding patients with suspected PHACT is inadequate to guide clinical decision making. No consensus has been reached regarding the management of Co-HP patients with systemic symptoms. Indications for chelation have not been established and require further study. Improved case definitions, improved surveillance, and controlled studies are needed to elucidate the scope of this problem and guide future investigations.

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Conflict of Interest

The authors report no declarations of interest. The opinions in this Review are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry. Dr. Brent reports that he has provided background scientific research as a paid consultant for DePuy Companies.

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Authors and Affiliations

  1. Georgia Poison Center, 50 Hurt Plaza, Suite 600, Atlanta, GA, 30303, USA

    John J. Devlin, Adam C. Pomerleau, Brent W. Morgan & Michael Schwartz

  2. Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA

    John J. Devlin, Adam C. Pomerleau & Brent W. Morgan

  3. National Center for Environmental Health (NCEH), Centers for Disease Control and Prevention (CDC), Chamblee, GA, USA

    John J. Devlin, Adam C. Pomerleau, Scott Deitchman & Michael Schwartz

  4. Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA

    Jeffrey Brent

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  1. John J. Devlin
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Correspondence to John J. Devlin.

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Devlin, J.J., Pomerleau, A.C., Brent, J. et al. Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: a Systematic Review of Cases. J. Med. Toxicol. 9, 405–415 (2013). https://doi.org/10.1007/s13181-013-0320-0

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