High cobalt level but still functioning well

[mountaingoat]

I posted on a few other threads earlier this winter because I was having some issues with my resurfacing (bilateral Dr. Gross in Jan. 2012).  Prior to January of this year I had zero problems - I had a near flawless recovery (although it was tough initially) and I was back to extensive hiking, cycling, yoga and I started skiing and light jogging at around 10 months post-op.  I began to have some post-exercise soreness in my left hip and then to a lesser extent in my right in early January. I rested for a few weeks and had x-rays done which looked perfect according to Dr. Gross. I resumed activity but was told to take it easy from impact activities for a few months. I have continued to xc ski, lift weights and cycle for the last few months with mild to moderate pain some days.  However, I am in no way significantly limited. I have spent multiple weekends doing long days of cross-country skiing for miles as well as hard spinning classes 3-4 days per week so I would not consider myself to be debilitated on any level by this pain. Still, I had zero pain prior to January.

In any case, I had two ultrasound exams of my hips spaced 6 weeks apart and a metal ion blood test as ordered by Dr. Gross. The ultrasounds were both negative - there was no abnormal fluid accumulation in either hip nor any evidence of effusion, tissue damage, pseudotumor, etc . However, my metal ion results did come back on the high side even for someone who is still in the run-in period for the device.  My chromium level was 3.6 and my cobalt came back at 9.6.  The recommendation I found from an article on this website was 7.4 for chromium and 5.0 for cobalt for bilaterals so I am slightly above the safe zone for cobalt. I am waiting to speak with Dr. Gross this week about the results. I suspect he will say to re-test in a few months to determine a trend.

I suspect that I do have some kind of mild metallosis or at least some kind of inflammatory reaction to the metal. My cup angles are perfect - left is 40 degrees and right is 32.  I do have some clunking and shifting that I did not really have earlier on. Interestingly, I do not fit the category for 'high risk' in that I did not have dysplasia, I am in no way petite (5'8 and 135lbs) and my cup angles are all excellent.

I plan to get a second opinion from Dr. Pritchett because of his work with women and metallosis and because he is now offering some women the opportunity for a revision to a metal on poly resurfacing instead of a THR. I suspect a revision is in my future at some point and I am really hoping I can retain my femoral heads even if I have to go to a less durable cup bearing like poly.

Of course I am deeply saddened by all of this but I guess because I have still been able to be active and do most of what I would like to do, I am not despondent.  I spent one weekend on a ski hut trip in the Colorado backcountry where I climbed uphill with my skis for over 3 hours and skied down so I can't say that I am terribly impacted by any of these issues. At least not right now. 

[Marco Polo]

Mountaingoat:

Thanks for sharing your update.  I am sorry you are dealing with this issue, but I am glad to hear that you can continue to participate in most of the activities you enjoy while you gather more information.  Getting a 2nd opinion from Dr. Pritchett seems like a good, proactive approach.  I saw a post on one of the other resurfacing Boards from a female patient of his that received the metal/poly device and she seemed quite pleased with the outcome.

[hernanu]

Hi Amy,

Sorry you have elevated cobalt levels. It is good that you have no symptoms or visible problems with the device and can do your activities.

As you mentioned, 9.6 is elevated, but not as high as many who have metallosis. Hopefully it stays stable and does not give you any symptoms. I think talking with Dr. Pritchett is a good step, to plan if you do need a revision in the future.

Hoping for no increase in your levels and no symptoms, but there are good alternatives if you do. I like your positivity.

[mountaingoat]

Thanks MarcoPolo and Hernanu.

To be clear, I do have symptoms both mechanical and physical but they are just manageable for the time-being and I am not in any debilitating pain. I definitely have bad days but I also continue to stay active and do most of what I want to be doing.

I'm less concerned about the metal ions than I am about tissue damage/muscle wasting from the metallosis. It seems like it really varies as to how long this takes to occur.

My biggest concern is not whether I have to have a revision because that seems likely at this point but whether I will be a candidate for keeping my resurfacing via a poly liner in the cup. I am worried that because Dr. Gross uses the Biomet and Dr. Pritchett uses the BHR there won't be cross-over within the devices.

Does anyone know if surgeons can use different brands in a revision than the original resufacing if they keep the femoral component?i.e. if you have a Biomet Recap femoral component and need a cup revision could you get a Smith & Nephew poly liner?

The universe seems to be throwing an unusual number of obstacles in my path. 

[Dee Dee]

Hi Amy,
Glad you posted about your condition. I was wondering if you got relief and saw your new post.  I am so sorry about this happening.  I hope you get some answers from dr Pritchett.

Keep us informed. Sharing your experience may help others.

Dee

[hernanu]

Sorry Amy, I had thought you didn't have symptoms. I checked some areas, did not come across that combination. The best person to talk to (obviously) is Dr. Pritchett, he may be comfortable with doing that for you.

Best of luck and keep in touch.

[mountaingoat]

Thanks Dee and Hernanu.

Update: I spoke with Dr. Gross yesterday about my ion levels. With all due respect to Dr. Gross as one of the world's best resurfacing surgeons, I am very frustrated at this point with how he and his office have approached my situation. He told me that while my cobalt levels are indeed elevated he believes it is still too early to tell anything and wants me to wait until January of 2014 (!!!) to re-test, at which time I will be two years out. More troubling was his assertion that there is *no possibility* that I could be having an adverse wear reaction to the metals because my components are perfectly positioned.  In his 3000+ patients with resurfaced hips he has had 8 adverse wear failures and all of those had steep cup angles and were before the use of intra-operative x-ray. I understand that my cup angles are right on target at 40 and 32 degrees but as we are all learning there have now been many instances of metallosis in patients with ideal cup angles (some of whom have posted on this board in recent years).  He brought up the Oxford study and said he patently disagrees with the idea that adverse wear failures can occur in hips with well-positioned devices so therefore my symptoms are unrelated.  I suggested that when taken together, the fact that I have some mild to moderate symptoms that I did not have at all until 1 year post-op, clunking and elevated cobalt levels is concerning for an adverse tissue response to the metal but he dismissed this. He also said that at 2 years post-op if my levels are above 10ppb (they are now at 9.6) then he will order more diagnostic tests but not until that time.

I am very disappointed in this process. I have researched this issue ad nauseaum and I know I am not over-reacting at this point.  I am also concerned about the consequences of NOT doing something, i.e. systemic problems and bone and tissue damage. I have had ringing in my ears and some light-headedness that comes and goes but I didn't bother mentioning those symptoms because I knew they would also be dismissed as unrelated.

I had 2 prior hip scopes in 2009 that ultimately failed and then spent 6 weeks on crutches followed by 4 more weeks with a cane (with a toddler no less) in order to comply with Dr. Gross' post-op protocol for resurfacing. I then finally had good results until these issues arose. To now be told that I have to wait another entire YEAR to do anything about this seems to show a complete lack of precaution on their part.

I am already in the process of trying to obtain a second opinion from Dr. Pritchett but I have definite fears that he may not be able to help me given that I have a Biomet device and he uses Smith & Nephew.  I could get some additional opinions from Dr. Su and Dr.DeSmet but the same concern is there in terms of them using different device brands.

Trying my hardest to take this as a set-back and get back up and keep fighting but today I'm just worn out.   

[Baby Barista]

First, I'll admit that I too would be very frustrated and probably freaking out if I was in your position. But try to step back for a moment from that and look at what facts you have in front of you.

Here's good news: Your chromium level is ok. Your cobalt level is elevated, but not near the level typically seen with adverse reaction to metal wear debris.

Most importantly, your soft tissue shows no reactionary damage.

The bad news: you have unexplained pain. And that's horrible. You had this surgery so you wouldn't have pain. I can't speak for Dr. Gross, but it would seem what he's trying to say, is that all known indicators for metallosis are negative at this point. So, what more could be done, other than waiting, retesting and seeing if the pain resolves itself?

I do think it's worth consulting a second set of eyes. Dr. Pritchett would be a good person to talk to.

I'm sure Dr. Gross has asked this, but are there any of your activities that could be irritating the hip? You mentioned yoga. There are some people who've reported developing psoas irritation and general inflammation, from the tendon passing over rim of the acetabular cup, when pushing the limits of their flexibility.

I'm not telling you what to do, but if it were me, I'd start all over from square one to rule out an overuse injury. Rest and ice for a few weeks. Then start back with just walking and see if the pain changes at all. Just a thought.

I hope you find answers and relief.

[Dan L]

Very sorry to hear, and hope you get some resolution or help soon.

I would add to the above cautionary comments re the pain and such (absent the elevated levels) and say you are still relatively early in the recovery.  I've read here a lot of people that continue to improve well beyond the 12 month mark.  I'm 17+ months after my first and it is still improving and there are minor peaks and valleys, so time is the one thing you may want to consider before looking for more medical intervention.

I'm not aware of what to expect with the elevated blood level, and not sure if that can improve or not over time, but the physical symptoms of discomfort certainly can.

Best hopes for something to get better.

Dan

[mountaingoat]

Thanks folks for the kind words and feedback. I really appreciate it as I have no one else to talk to about this at the moment...I haven't been able to stomach even telling friends or family about it yet because it all seems so unreal that this could happen just a year + after my resurfacing.

Baby Barista - I did modify my activities basically most of the winter. On the advice of Dr. Gross and another local sports medicine doctor I saw here in Colorado I kept away from impact sports for basically 8 weeks and just hiked, walked, used the spinning bike and occasionally cross-country skied. I also did an initial period of complete rest for about 2 weeks. If anything, I seem to feel better with activity than when I do nothing - it keeps the joint moving and prevents the inflammation from just accumulating in the tissues around the joint.  I would stay off it for 2 months completely if I thought it would really help at this point. I agree with all you've said about looking at the positive...its true that my levels are not as high as some we've seen here on this board.

In terms of discomfort and physical symptoms, the pain in my left (worse) hip comes and goes with severity but its definitely there every day and the post-exercise soreness is pretty substantial sometimes. If I had had mediocre results from my resurfacing initially then it would probably be less dramatic but because I was completely pain free for nearly 10 months I know that something is not right and its not just muscle imbalances, etc. I agree that it does not yet make sense to jump the gun into more surgery but I am also leary of waiting a full year to do anything if I am in this much discomfort. Which is why I wish Dr. Gross would give me a bit more attention at this point.

I was able to speak with Dr. Pritchett yesterday evening. He is an extremely nice man and was very helpful. He basically confirmed my opinion that I do have some kind of metallosis developing and although its still in the early stages at this point we don't know what will happen. We discussed the surgical options in terms of revision to poly on metal but retaining the resurfacing - he is the only one doing this right now in the US. Ideally, of course, I would just have the socket revised and a poly  liner put in so that there is no metal on metal articulation but the problem he is currently encountering is that he cannot get access to enough cup sizes to match the existing femoral heads and its become something of a problem for him. Apparently, he used to be able to sort of "custom order" parts for people based on their anatomy but his hospital is contracting with Stryker and its become more difficult.  He is also revising some people with a poly head and keeping the socket but this would really not be my preference because of the bone loss - its not a full THR revision because he is able to use an anatomical sized head since the cup is still large enough but it still requires the removal of the bone which at 37 I am very reluctant to do. So, I'm going to send him my x-rays and he is going to look into what sizes he thinks he can get...Ironically, he has plenty for smaller boned women but I currently have a size 48 head and thats considered on the large size for women. 

In the meantime, I'll have to think about what to do. I really still would like this all to go away and just be a bad dream! I guess I will probably do another ion test in 2 months to see what the trend is and go from there. He said he would not advise waiting more than 6 months or so to do anything about it given the risk of more tissue damage.

Goodness. To think I would ever be in the position of not being able to obtain the right sized prosthetic component for my hips!  Not really something you contemplate in your 30s! But I guess this is something of a first world problem 

Amy

[hernanu]

Well, Amy - I'm glad you're getting the lay of the land on this. It is bad that you have to face this, but excellent that you're getting some positive action.

I'm psyched for you that you have the option of revising the cup, looks like Dr. Pritchett is on the job. Have you had any MRI's to see the tissues around the site?

At the least you have a good option and a good revision in your future.

[John C]

Hi Amy,
Sorry to hear that you are dealing with this, after feeling so good for awhile. I agree with Hernanu's suggestion to consider an MRI. It seems like your biggest concern at this point is whether there is any soft tissue damage accumulating. Having an answer to that question would help guide you as to whether you can afford to wait until January, or whether you need to pursue some other options. I have a vague memory that you were looking at having an ultra-sound a while ago. If that was not conclusive in terms of the soft tissue, maybe an MRI would give you a clearer sense of whether you need to worry. If the MRI comes back without major issues, it might lend credence to Dr Gross's view that the marginally high ion numbers could be due to the break-in period, and might return to normal when you are past that at two years.
We all wish you the best, and hope that a relatively easy solution presents itself.

[mountaingoat]

Thanks  John and Hernanu.
 Yes, I'd like to be able to get a bilateral MRI to check for soft tissue damage or fluid accumulation. I've had 2 ultrasounds and neither seemed to show fluid in the hip but there would be no way to tell about actual muscle damage. I know Dr. Gross wasn't interested in ordering a MARs protocol MRI but perhaps I can have Dr. Pritchett order one.

When I asked Dr. Pritchett how long he thought I could let this go he didn't have an answer for me. He laughed and said all his Alaska patients beg him to let them wait until the end of the summer because summer is so great up there so he feels like he has to acquiesce...well I told him summer in Colorado is pretty darn nice too! 

I still sort of can't fathom that this has all happened so quickly when I was skiing and starting to get back into jogging around Christmas time without so much as a thought about my hips other than some residual weakness....makes you really think about how you never know what is in store for you!

[Dee Dee]

Wow Amy,

I am so sorry for what you are going through. I hope you can get the MRI and potentially get more answers.  It must be so difficult knowing how well you were doing and then "bam" you are caught off guard with pain and no definite answers.  We trust the medical community with our bodies and our lives. We want them to respond when things don't go as planned/expected.  Keep searching for answers, you are your best advocate. Let us know about your journey.

Blessings,
Dee

[Toontowngal]

I too have high levels which is why I had a THR for my second hip. It was too risky to the rest of my health for do another resurfacing. Canada is not doing many resurfacing anymore due to high levels. I love my resurfaced hip more so than the THR but what can you do?! Due to the unknown of what high metal levels can do to our health is unsettling ....

[Gazza2]

...... Canada is not doing many resurfacing anymore due to high levels ....

where did you hear that? -  here in Ottawa they are still doing them.  Well 8 wks ago for sure!

[PattyM]

Wow,
this post is making me nervous! I have to cobalt hips, and have been thinking
about basing  my meals around foods and herbs that remove metals from the body.
Yikes!
Patty

[cwg]

Hey there- Don't worry so much. Your levels are not that big , and only one, not both. I speak from much higher levels, 6 years later,, and watch them go up and down
Keep exercising! Do what you can.
Don't obsess. Zero need to do that .
I speak from much experience
Contact me privately if you wish
cwg
merde :-)

[CEK001]

Hi everyone! 

MountainGoat please let me know your outcome!  I have a 5+ year BHR and just found out I also have elevated chromium and cobalt levels.  The doctor ordered me a MARS MRI, but started to speak about a revision to a THR with ceramic. I have been doing nothing but crying since yesterday when I found out.

I am a month short of 49 years old.  I have been a runner my whole life - completed marathons before this all began.  Just last year I got back into running as my hip finally felt strong enough to handle it.  And I've been increasing my mileage and training for a half marathon.  Sure my hip feels a little achy, but not too bad and I've been dealing with constant pain for 10 years. (two previous surgeries to try to fix FAI)

Before I jump off the ledge, please let me know what your outcome was....  I just can't wrap my head around another surgery in so short a time.  I thought I had a little more time and I've been so happy lately with my increased activity....

Christine

[catfriend]

CEK - I just sent you a pm.