Cobalt toxicity; Realted to Clunking hip

[Pete C]

OK, let's get serious here. I have had a BHR since 07/08. After about 6 months, and the beginning of my exercise re-start, the clunking sensation began. It continues. In addition, in the past year, i have noticed increased pain in the resurfaced joint, especialy after exercise. It is almost like the arthritis pain i had before the surgery, with the exception that i used to "know" that nothing can be wrong in there due to the implants. In addition, there have been several incidents of a SHARP pain when putting loads on this resurfaced hip, at odd angles. This happens totally unexpectidly, and i can not repeat the painful movement. It just bites at random. Well, i was just advised that the mechanics of the clunking may be giving off cobalt ions, shavings, whatever, and that these may be the beginning of a reaction in the tissues there. The sharp pain is, apparently, tissue growth around the metal joint, which is a reaction to the irritation of the cobalt, and then said tissue gets "pinched" in the tight space between the ball and the cup. Very disturbing. Today, i had a blood test to determine the cobalt levels in my blood stream. I can tell you more about the levels i was told we are looking for, and what might be a "bad" sign level, in a later post. What i can say is that it was indicated that depending on the cobalt readings, i may have to have the acetablular component repositioned, or a revision to THR may be next. Needless to say, i am not happy about these propects.
I would appreciate any input or hearing from anyone who can relate similar experiences on this topic. Anybody else had a story like this? Definitely has put a pin in my bubble of satisfaction with this procedure.

[Big Bill]

Big Bill here .... OK I will nibble at your hook ....as you say ..."let's get serious"...who says what...where is your info (medically ) coming from...who told you this ...who was you surgeon   Not trying to ring your bell....but ....let's get serious        .

         Big Bill

[Pete C]

All this comes from the surgeon. He's done over 1500 resurfacings. 

[Big Bill]

Big Bill here...We will be interested to hear what happens with your follow up with Dr. Pritchett and ultimately wish you the best !

         Big Bill    AKA   C.A.S.H.   

[Pete C]

Thanks for the words of support. Will certainly follow-up with the results, and next steps, as soon as we know.

[Pete C]

OK research, Bill.

First blood test = cobalt 86.7 micro grams/ltr.  Next, 2nd serum test, followed by MRI. Possible fluid withdrawal to confirm tissue necrosis (having some fun now). 

Then, decide on immediate course, acetab repositioning (?) or THR.   Am sure you can see where all this is going. Not good.

"If i only knew then, what i know now."

Updates to follow. 

[Dayton96]

Pete:

Did Dr. Pritchett have an explanation as to what happened?  Were you a particularly difficult case?  Did he just have an off day?

[Pete C]

Just wanted to post an update. On Friday, 10-8-10, i will have a revision to a THR to replace a 2-year old BHR. The reason is increasing pain in the joint, and the larger concern is metalosis by cobalt poisoning. The root cause for this resurfacing failure is improper location of the acetabular component. It is at an angle of 60 degrees, possibly very close to my natural angle before surgery. Many patients have been loaded with resurface acetabular cups at greater than 60. Due to this acute angle, and failure to adjust for this during the initial placement, my hip parts are 'edge-loading' a great deal of the time. This throws off metal ions, which are in my blood stream and have attacked the surrounding tissue. That dead tissue will have to be removed, but i am told it will rejuvenate over time. Ultimate faliure would occur if the metal attacked the bone, so we have to do the revision now. You can google cobalt ions in blood to read some of the other unpleasant effects of this (i.e. my ears are ringing as i write this).
Note: the miss-placement of the acetabular cup is the root cause for the "clunking" sensation so many BHR patients feel. I have beeen told that upwards of 25% of resurface patients experience this. The two parts want to be polar-aligned. When they are not, edge loading and ion discharge will result. Some number of the patients who experience this now (who knows how many?) will eventually have exceessive cobalt ion counts. When that is discovered, you are looking at either a revision of the acetabular, or a complete THR.
What can you do about this? New resurfacing patients can learn before surgery what angle the surgeon plans to place the acet. comp. The doctor should be very familiar with the risks of acute angle placement, and how to engineer this in correctly. The max angle of placement (i have been told) should be 40 degrees. This focus on acetabular component angle is relatively new to the doctors who are doing resurfacing. Am pretty sure it was not a concern of my doctor when he did my op 2 years ago. You should insist on intra-operative x-rays to verify the placement before the surgery is concluded. Annual followup tests, and a blood test for cobalt (not cheap) should be the norm for anyone is experiencing clunking or the feeling of movement in the joint.
If you elect to revise just the acetabular component, be aware that this is very similar to the original resurface operation. Whereas the newest technique for THR first-time placement involves an anterior approach, which is less invasive and easier recovery, going to a THR from a resurface, most of which were placed posteriorly, will have to use the same approach as the first time. In addition, the condition of the remaining original femoral component, even with a new acetabular cup, should be a consideration. That wear, or galling, of the two pieces has likely produced some amount of deformation of the femoral ball. How is that worn ball going to fit smoothly with a new cup? Ultimately, that logic was the reason i VERY reluctantly chose to have the THR. It was one of the toughest decisions i have ever made. I wiil be requesting and receiving the removed, worn cobalt pieces after my revision. I will let you know the results after i see them.
I apologize for the long post. This is a very deep subject. Patients who have received or are considering receiving a metal-on-metal hip resurface should know what they are 'walking into'.

[John C]

Hi Pete,
First, I want to thank you for taking the time to post the details of your journey. As you said, it is important for people considering this surgery to be aware of all of the potential issues that can come up, and to approach their surgery as an educated part of the team.
I do want to address one comment in your post that might cause unnecessary concern. You said that "the miss-placement of the acetabular cup is the root cause for the "clunking" sensation". While I am sure that this is sometimes the case, I do not think that everyone experiencing some minor clunking should assume that they have placement or ion issues. I had a fair amount of clunking early on, and occasional minor clunks still; however my cup is at an ideal 39 degrees, and my Chromium ion count is at a very low 1.39 which is within the range for people without any metal prostheses. So, while I do think that everyone should be responsible to be on top of their cup placement and ion levels, I do not think that people should necessarily assume that some clunking, especially during early recovery, means that there is a serious underlying problem.
I wish you the best of luck with the revision surgery. I am confident that your choice to revise to a THR is a good choice, and will work out well for you in the long run.

[Pete C]

John,  With all due respect, and my hopes for your continued good health, i would question whether any level of cobalt ion count in blood is normal. The lab report on my level lists the "reference" level at something less than 1.0 ug/L. Other studies and lab levels i have seen show normal levels as being .03-.8 ug/L. Certainly, most of what i have read, and of course,my case entirely, is anecdotal. But i think it is safe to state the root cause for clunking. And, it is my conclusion and that alone, that clunking of the metal on metal joint will produce some level of ion discharge. Perhaps, the great majority of resurfacing recipients will never experience high cobalt/blood levels. But i am convinced that it is something that every patient of this process should be aware of. And, unfortunately, it is an increasing trend in the overall resurface patient population.

[Pat Walter]

I am almost 6 years post op from Dr. De Smet of Belgium who has done way over 3000 resurfacings.  I have a great deal of info posted by him and video interviews.  The clunking, according to him and many other surgeons, is not due to mis-aligned or wrongly placed acetabular cups, but from weak muscles not able to hold the two components together.  I had the clunking along with many other people.  I never had pain and never required a revision as thousands of others have experinced.  I want to make sure new people understand that most clunking is normal and does not happen because of an acetabular cup that is misaligned. http://www.surfacehippy.info/faqclunkinginhip.php

Aso there is always a small increase in the metal ion levels after having a hip resurfacing or having a MOM THR.  The MOM THR and hip resurfacing acebaular cups and femur caps are the same components.  There have been a number of medical studies about this increase including special studies for athletes.  Here is a basic discussion of the increased metal ions after surgery  http://www.surfacehippy.info/faqmetalions.php    Here are a number of studies and articles about metal ions after resurfacing  http://www.surfacehippy.info/metalioninformation.php  This includes Mr. McMinn's very informative video interview about the subject and all the negative press.  http://www.surfacehippy.info/mcminnnegativepr.php

Every potential patient must make up their own minds, but it is good to use information from the experienced surgeons to learn.  The negative info is general from the less expeirnced surgeons that are having diffiuclties placed acetabular cups properly.  Many of them have stopped doing resurfacing and are now very negative.

Make sure you read good information and not just patient's opinions in determing what solution is best for you including hip resurfacing and MOM THRs.

It often seems that there are so many patients with problems and revisions due to the large number of posts, but normally the happy resurfacing patient with well placed components are not posting stories on discussion groups.  They are off and enjoying their new active lives.  I also have hundreds of sucessful hip resurfacing stories posted  http://www.surfacehippy.info/hipstories.php

I understand how dissapointing it is to face a revision and also there are a small number of people that actually have allergies to colbalt/chrome.  My heart goes out to those people, but I also have to present the overall sucess rate of hip resurfacing.

Pat

[Pete C]

Pat,
I appreciate your point of view. Doctors and specialists are supposed to be our experts, and we are conditioned to expect and depend on their guidance in all health-related issues. That is the way it should be.

Unfortunately, the field of medicine has become a competitive business, assuming, of course, that it wasn't always so. Doctors, medical equipment provider businesses, and the health care industry surrounding them, all have a huge vested stake in the public perception of their products and services. I'll leave it at that thought.

I re-read my post. My intent was and is to offer an experienced patient's point of view, for others considering such a procedure, of some serious questions and considerations that might otherwise not come up in the pre-surgical meeting with the doctor. The days of patients placing their lives in the complete trust and care of healthcare providers are over. We each need to exercise an active and learned role in what is going on.

I stand by everything I wrote.
Pete

[Tommy]

Pete
   First I want to say good luck with your revision. I'm married to a health care provider and I let her read your post and we could not agree with you more when you said, " The days of patients placing their lives in the complete trust and care of healthcare providers are over. We each need to exercise an active and learned role in what is going on." Thank you for shareing your point of view.
                                                Tommy

[jack]

I guess my biggest concern would be that if the surgeon screwed up the resurface what are the chances of the same thing happening with the THR? Same kind of deal with the Acetabulum cup for both procedures. Good luck none the less!

[Pete C]

Jack,
Your point is well taken.

This revision surgery was researched EXTENSIVELY. As an engaged, involved patient, i made sure that every foreseable issue was addressed beforehand. We/I put off the operation date, in spite of the huge Cobalt level number, to make sure that tests were coducted and that all angles were considered. Today is only five days post-op, but the outcome so far has been excellent.

[jack]

Note: the miss-placement of the acetabular cup is the root cause for the "clunking" sensation so many BHR patients feel. I have beeen told that upwards of 25% of resurface patients experience this. The two parts want to be polar-aligned. When they are not, edge loading and ion discharge will result. Some number of the patients who experience this now (who knows how many?) will eventually have exceessive cobalt ion counts. The max angle of placement (i have been told) should be 40 degrees.

The max angle is 40 degrees. You are correct. My placement wound up at 39.6 degrees. Cannot ask for more than that, BUT I still had clunking as well albeit not a lot and not for long. One cannot randomly say that clunking is caused entirely by a misplaced cup. There are many other factors. Many people have this clunking with properly placed devices. It is the edge loading from the misplacement that causes the 'ball' to place weight on the edge of the cup. This loss of weight displacement along with the knife edge sort of action is where the high wear occurs.

This focus on acetabular component angle is relatively new to the doctors who are doing resurfacing. Am pretty sure it was not a concern of my doctor when he did my op 2 years ago. You should insist on intra-operative x-rays to verify the placement before the surgery is concluded. Annual followup tests, and a blood test for cobalt (not cheap) should be the norm for anyone is experiencing clunking or the feeling of movement in the joint.

Wow, if your doctor was not concerned with placement of your cup, I sure would not have let the guy work on me again for any reason. I am pretty sure that would have been right up there on his list of priorities.

I wiil be requesting and receiving the removed, worn cobalt pieces after my revision. I will let you know the results after i see them.

This would be interesting to see for sure. If you can see wear, perhaps you can post a picture for us all to see!


Glad you made it through surgery and the outcome is good. Keep your chin up, if done properly this one should last you the rest of your life!

[toby]

Pete,
Glad to hear that your THR was successful and that after 5 days the recovery's going well-you deserve some good luck from here on.
I see from Jack's reply that he confers with your earlier point that 40 degrees is the 'maximum' inclination angle. From all my research and understanding 40 degrees is the 'ideal' rather than maximum angle (mine's spot on 40 incidentally). In the latest Mcminn presentation he talks about 'shooting for 40'. Also, my understanding is that surgeons must also take into account patient anatomy/orthopaedic circumstances etc in order to determine ideal angles-including anteversion considerations on both the femur and acetabulum. From the retrieval studies in both the US and UK, the small percentage of HR problems (let's not forget that the data in the registries show generally speaking an average 96% success rate-some surgeons like Treacy, Mcminn, De Smet, Bose et al 98% plus at 8 years) occurred at inclination angles above 55 degrees. I wouldn't want to worry those whose angles are above the ideal but still performing perfectly well.
Keep Up the Progress
Toby

[jack]

Ahhh yes good point, I misspoke. 40 degrees is the 'optimum' angle.   

[cwg]

PETE C  Where are you at right now? !  This thread was very informative.. and useful.

cwg

[B.I.L.L.]

PETE C  Where are you at right now? !  This thread was very informative.. and useful.

cwg

Pete C  - Last active June 4th 2011.  Sounds like Pete C has left the building. I would like to know what kind of thr he got and how well it's performing as well. Since he hasn't been poking around in here for over 4 months I'm guessing he is probably doing fine, I hope so for his sake