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Published on: September 4, 2016
Myocardial Cobalt Levels Are Elevated in the Setting of Total Hip Arthroplasty
Cody C Wyles1, T Carson Wright, Melanie C Bois
11College of Medicine (T.C.W. and S.P.W.) and Departments of Orthopedic Surgery (C.C.W. and R.T.T.), Laboratory Medicine & Pathology (M.C.B., M.S.A., A.F., P.L.D., D.L.M., W.D.E., and J.J.M.), Health Sciences Research (S.M.J.), and Cardiovascular Diseases (N.S.A. and J.J.M.), Mayo Clinic, Rochester, Minnesota.
Insights
Total hip arthroplasty (THA) patients showed higher myocardial cobalt levels than controls. Elevated cobalt, cardiomegaly, and fibrosis were observed in THA patients, suggesting potential cardiac effects from joint replacement implants.
Area of Science:
- Orthopedic Surgery
- Cardiology
- Toxicology
Background:
- Arthroplasty implants can release elemental metals.
- Myocardial injury has been reported in hip implant cases.
- Systematic measurement of myocardial metal levels post-THA is lacking.
Purpose of the Study:
- To systematically measure myocardial cobalt (Co) and chromium (Cr) levels in patients with total hip arthroplasty (THA).
- To investigate the relationship between THA and myocardial metal concentrations.
- To assess cardiac pathology in relation to THA implants.
Main Methods:
- Autopsy archives were queried for THA cases (1990-2013) and matched controls.
- Myocardial tissue samples analyzed for Co and Cr using inductively coupled plasma mass spectroscopy.
- Seventy-five THA cases and 73 controls were included.
Main Results:
- Significantly higher median myocardial Co concentrations in THA patients versus controls (0.12 vs. 0.06 μg/g, p < 0.0001).
- Median Co concentration was 69% higher in THA revision cases compared to primary THA.
- Cardiomegaly, interstitial fibrosis, and reduced ejection fraction were more frequent in THA patients.
Conclusions:
- This is the first study quantifying cardiac metal levels in THA patients.
- Elevated myocardial Co levels, cardiomegaly, and fibrosis are novel findings in the arthroplasty cohort.
- While Co levels were elevated, most remained below those associated with fatal cardiotoxicity from metal-on-metal prostheses.
Background:
Arthroplasty implants commonly contain elemental metal that may undergo wear-related release. Recently, cases of hip implant-associated myocardial injury have been reported. However, we are not aware of any previous study that has systematically measured myocardial metal levels or examined the relationship with total hip arthroplasty (THA).
Methods:
Archives of our institution were queried for autopsies of individuals who had undergone THA between 1990 and 2013. Myocardial tissue samples were analyzed for cobalt (Co) and chromium (Cr) levels with inductively coupled plasma mass spectroscopy. Seventy-five Co/Cr-on-polyethylene THA cases were included (mean age at time of death = 77.4 years; 49% women) as were 73 non-arthroplasty controls matched for age, sex, and history of hypertension and diabetes mellitus.
Results:
Significantly higher median myocardial concentrations of Co were observed in individuals with THA compared with controls (0.12 versus 0.06 μg/g, p < 0.0001). The median Co concentration was 69% higher in patients who had undergone THA revision (0.169 μg/g) than in those who underwent primary THA (0.100 μg/g; p = 0.004). In general, higher Co levels were observed in those with multiple replaced joints, although this finding only trended toward significance. Cardiomegaly, interstitial fibrosis, and decreased ejection fraction were observed more frequently in the postmortem samples of patients with implants than in those of controls (p = 0.0002, 0.044, and 0.0039, respectively).
Conclusions:
We believe this to be the first study to quantify metal levels in cardiac tissue in patients with and without joint replacement. The elevated Co levels, in concert with cardiomegaly and increased interstitial fibrosis found during autopsy, in the arthroplasty cohort are novel, important findings. Although Co levels were significantly elevated above those in controls, the majority were below those seen in clinical case reports of death from Co cardiotoxicity associated with metal-on-metal prostheses.
Level Of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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