Subclinical systemic metal toxicities

[Rn2md]

I’m planning on having a resurfacing procedure soon, but came across some disturbing scientific presentations by Dr. Stephen Tower and Dr. Robert Bridges.  They Claim to have identified various neurocognitive and other systemic toxicities in patents with cobalt levels >1Ppb, less than most feel are clinically significant based on surgeons protocol threshold values. The studies they did seemed pretty robust, even with FDG PET brain mapping. Although the sample size was only 101 patients.
This caught my attention though, since the abnormal metal level thresholds used in many surgeons surveillance protocols are based on values most likely seen with local joint wear complications but not necessarily on other systemic sequelae.

This might at least suggest that it’s worth checking other clinical parameters regularly beyond the joint.

The videos are on you tube.

Be happy to hear anyone’s thoughts or especially if any one has noticed the extraarticular manifestations they described at lower metal levels.

[Pat Walter]

Interesting, but they only studied 101 patients.  There are 5000+ patients right here on this discussion group with the majority actually having a hip resurfacing.  Also very few with any metal ion problems.  I also have over 1500 personal hip resurfacing stories posted with very few revision stories.  There are also thousands of successful hip resurfacings done world wide.  Just look at the stats for the top surgeons.


So I think this is a very small group and who were their surgeon and what devices did these people have.  It is widely known that hip resurfacing components must be very precisely placed or there is edge wear leading to high metal ions.  Without knowing the surgeons and devices, this does not really tell much.  It is known that many lesser experienced surgeons no longer do hip resurfacing because they had many problems and also many surgeons don't train to do hip resurfacing because it is a much more difficult surgery.


I don't think a small study of 100 people with resurfacings not done by the top surgeons with the top devices really shows anything, but that is only my opinion. There are a lot of doctors who are against hip resurfacing and they certainly seem to get more press than the very experienced surgeons with great outcomes.


Pat

[blinky]

Have you started talking to a surgeon yet? If yes, run it by him for the best, most complete, and up to date answer. (Once I had a surgery date with Dr Gross, I used to email "but what ifs" to his office. Post op I was still doing it, like if I read the FDA had a new reg or something like that. I'd say "does this new reg affect you? Me?")

Tower has been around a while. At least some of what he is saying isn't new. I came across him three years ago when I was pre op. Are these just youtubes? Can you get your hands on the studies themselves? Where were they published? When? What reaction have they generated in the scientific community?

[Rn2md]

Yes, and at the time of discussion, I hadn't seen this particular take on lower cobalt levels. I'll probably inquire though. Yes, I'm scheduled with Gross.
The thing about it is, I wonder if most surgeons would spend time checking for these types of non-orthopedic problems, particularly if the metal levels were in the "Normal" range and there was no pain, etc. And most patients may not think to report them for the same reasons even if present. General physicians and patients would probably attribute the problems to something else, even if identified.

But no real conclusions can be drawn from those videos, given the small number of patients. I imagine it would probably take a large retrospective NIH funded study to confirm or refute the observations made by Dr. Stephen Tower and Dr. Robert Bridges. Who knows if that would ever happen.

In case there ever turns out to be a grain of truth to this, I wonder if it wouldn't hurt to inquire about checking ion levels longer term, given that implants placed by an excellent surgeon may well last a lifetime, and routine metal ion checks aren't always done beyond a certain number of years post implantation.

[blinky]

Run it by Dr Gross. He will give you a serious, thoughtful answer. I wouldn't be surprised if he is familiar with these arguments. (I looked at a bit of the videos---I am supposed to be cooking for company---and did watch them pre op. I am guessing I searched for medical/scientific reaction and didn't find any.)

[hernanu]

Yes, and at the time of discussion, I hadn't seen this particular take on lower cobalt levels. I'll probably inquire though. Yes, I'm scheduled with Gross.
The thing about it is, I wonder if most surgeons would spend time checking for these types of non-orthopedic problems, particularly if the metal levels were in the "Normal" range and there was no pain, etc. And most patients may not think to report them for the same reasons even if present. General physicians and patients would probably attribute the problems to something else, even if identified.

But no real conclusions can be drawn from those videos, given the small number of patients. I imagine it would probably take a large retrospective NIH funded study to confirm or refute the observations made by Dr. Stephen Tower and Dr. Robert Bridges. Who knows if that would ever happen.

In case there ever turns out to be a grain of truth to this, I wonder if it wouldn't hurt to inquire about checking ion levels longer term, given that implants placed by an excellent surgeon may well last a lifetime, and routine metal ion checks aren't always done beyond a certain number of years post implantation.

I asked for a metal ion test last time I was checked by my surgeon (they came out well), and plan on doing so this year at my nine year checkup.  I think it's important.

You have to be your own best advocate, so if it is important to you to have that done, then instruct them to do so. I do and have.

Having said that, cobalt is a naturally occurring substance and is in fact necessary for a healthy life (it is in vitamin B12). We ingest it daily. So it is expected to be in your body.

Here's an informational writeup from the center for disease control.

https://www.atsdr.cdc.gov/phs/phs.asp?id=371&tid=64

Of course, anything can become toxic in excess, and in our case we have a possible source of toxicity within us.

The accepted levels are higher than what is in the paper you noted.

As informed and careful people, we must always be vigilant, but at the same time look at large scale studies that have been done to compare the cobalt levels and the actual medical outcome - health effects and revisions.

Any new information should be perused carefully, but we also have to look at all of the research that has been done and use that to provide context.

Talking about this with Doctor Gross is a good idea.

[Saf57]

The experienced resurfacing surgeons most mentioned on this site have implanted(and this is just a guess) tens of thousands of MoM resurfacing devices, with great success. While there have been reported instances of complications/revisions due to metal ion issues, this is an extremely low percentage. Moreover, even among this group, the type of symptoms being warned about by this surgeon do not appear to have been reported. This physician seems to be on sort of a mission to get the word out on the dangers of MoM implants, driven by his own experience in being the recipient of a failed MoM THR(he also installed some as a surgeon), which device was subsequently taken off the market, along with other MoM THR devices. This is to be contrasted, I believe, with the long term successes of MoM resurfacing.

[Rn2md]

Thanks to Pat, Blinky, Hernanu, and Saf57 for the helpful and informative commentary.
Considering a procedure that most orthopedic surgeons seem to disagree with, requires a careful individual to be that much more informed and aware. Even as a physician, I have needed to read quite a bit to get up to speed on this procedure, and then more to separate the facts and evidence from the opinions, biases, and eccentricities.

I agree that care and vigilance are necessary, as well as viewing new information in the context of published results.  Yet I also know in general that there are many barriers to reporting and publishing, particularly with respect to negative outcomes or other untoward health effects. So it also seems likely that certain truths may exist well before publication.
With that in mind, this website has been a wonderful resource for getting unbiased, honest and accurate information.

So thanks again for helping keep things in perspective

[Pat Walter]

It is always difficult to decide what is important and valid, by what is often reported.  My opinion agrees with the top experienced surgeons who each have done 4000, 5000 or more hip resurfacings each. They make their statistics public and available if you read or ask them.  Their outcomes are based on many thousands of patients who have had their hip resurfacings many years. 


It takes a long time to develop a new hip device and get it FDA approved.  Because of that, there are very few devices available in the US.  I remember when several of the now, removed devices first came out.  People read about them as said - I want it.  But there was very little information or experience with them.  Ultimately, they were not very successful and removed from the market.


So with the new, small studies, until there is a large pool of information to agree and prove the theory correct, I don't think people should jump to any conclusions about hip resurfacing.  Right now we have 100,000+ patients with successful hip resurfacings.  Yes, there have been some failures, but very few in the scheme of things.  There is never any surgery, device, etc that will ever be 100%.  Even THRs have many failures and problems.  So we, as patients, have to read and learn, then choose what we think is best for us at the time.  Right now there are thousands of successful hip resurfacings.  Thousands right here on this discussion group and website.


So we have human bodies that all differ in small ways, human doctors who do their very best and manufactured devices that should all be the same.  But, there is never any guarantee that everything will be 100%.  Unfortunately, that is life.  Make your best choice at the time and live with the outcomes.  Don't second guess yourself after the surgery. It was the best decision at the time based on everything you could learn and read.


Decide on a surgeon and put yourself in their hands.  We put our lives in the hands of jet pilots everyday.  We chose the flight and they control the outcome. We hope all goes well. 


Pat