Heart transplant secondary to cobalt toxicity after hip arthroplasty revision

Abstract

Introduction: Cobalt toxicity in patients with hip arthroplasty is a rare complication, but it should be considered in those patients who, after a ceramic fracture, were implanted with a metal-on-polyethylene prosthesis. The complete removal of ceramic particles during revision surgery can be complicated. If the bearing surface is replaced with a metalon-polyethylene prosthesis, these residual ceramic particles may wear down the chrome-cobalt head, producing localised metallosis. This can trigger blood metal ion levels to rise, causing systemic toxicity. Visual and auditory alterations, cognitive deterioration, hypothyroidism, neuropathy, cardiomyopathy, anorexia, fatigue, diabetes, polycythemia, and respiratory and cutaneous symptoms are some of the clinical manifestations of prosthetic cobaltism. Case description: A young patient presented with multiorgan failure secondary to cobalt toxicity after a ceramic fracture and revision with a metal-on-polyethylene prosthesis; his serum cobalt and chromium levels were 652 μg/L and 270 μg/L, respectively. The patient needed a heart transplant after presenting with cobalt-induced cardiogenic shock. Conclusions: In a patient with a ceramic fracture who is subjected to revision surgery with a metal-on-polyethylene bearing, it is necessary to rule out the possibility of cobalt intoxication. Serum cobalt levels > 20 μg/L are inadmissible; in these cases, surgical treatment should be considered in the short term. A wide synovectomy and replacement of components should be performed with hard friction options, preferably with a ceramic-on-ceramic prosthesis.

Cobalt exposure in relation to cardiovascular disease in the United States general population

“…Previous studies have reported many cases of CVD caused by a cobalt poisoning dose, and suggested that THA patients with higher doses of cobalt presented with more severe CVD (Dahms et al 2014;Fox et al 2016;Samar et al 2015;Sanz Pérez et al 2019). Due to a lack of data about a possible association between cobalt and CVD in the general population, our research aimed to ll this knowledge gap.…”

“…Case studies of severe cardiomyopathy have revealed the association between poisoning cobalt doses and CVD due to the increased use of metal-to-metal (MoM) hip implants in patients undergoing total hip arthroplasty (THA) (Choi et al 2019;Sanz Pérez et al 2019). The blood cobalt levels of these patients could reach a fatal dose, as high as 641.6 μg/L (Dahms et al 2014;Fox et al 2016).…”

“…The blood cobalt levels of these patients could reach a fatal dose, as high as 641.6 μg/L (Dahms et al 2014;Fox et al 2016). Therefore, serum cobalt levels > 20 μg/L are not allowed in patients given a MoM hip implant (Sanz Pérez et al 2019), and at > 7 μg/L, clinicians should begin to observe the heart function (Tower 2010).…”

Cobalt-induced cardiomyopathy – do circulating cobalt levels matter?

“…There is a clear requirement for future experimental study design to take a more focused approach with stringent inclusion/exclusion criteria around cobalt levels being considered. Elevated cobalt at levels over 250 µg/l have been shown to be a risk factor for developing systemic complications, 5 and published case reports document cardiac transplantation 43 , 45 , 48 , 53 , 54 and death 46 , 51 , 52 , 55 , 59 in patients with severely elevated blood cobalt ions. Currently it is unclear whether there is a hard cut-off value and cardiac dysfunction may occur at cobalt levels less than 250 µg/l ( Table II ).…”

“… 52 Echocardiographs most commonly demonstrated a decreased left ventricular ejection fraction 42 , 43 , 45 - 47 , 49 - 51 , 53 , 57 - 59 , 61 but also a dilated atrium, 42 diastolic dysfunction, 39 - 41 , 47 left ventricular hypertrophy, 53 , 56 , 62 and a pericardial effusion. 52 , 53 Outcomes have varied from full recovery after revision surgery 39 - 42 , 44 , 47 , 53 , 56 , 58 , 60 or chelation therapy, 53 , 57 , 61 , 62 to left ventricular assist device implantation, 49 , 50 to cardiac transplantation 43 , 45 , 48 , 53 , 54 or death. 46 , 51 , 52 , 55 , 56 , 58 …”