Clinical cases of patients with arthroplasty and heightened blood concentration of metal ions

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We report on several clinical cases of different appearance and complications of patients after THR with metal-on-metal (MoM) couplings or a revision knee system. There may be skin irritation mainly due to chromium hypersensitivity or systemic effects and even cobalt intoxication can appear. We recommend clinical control to patients with MoM and a head size of 36 mm or larger or with knee revision systems. Patients who have problems such as pain or mal positioning should have measured the metall ion levels of cobalt. A serum cobalt level of >7 µg /L indicates possible periprosthetic metallosis and may cause trouble. A normal serum cobalt level is below 1 µg /L. We also need an MRI with Metal-Artifact-Reduced-Sequences or if not possible an ultrasound investigation to detect pseudotumors around the hip joint. For the clinical investigation you should look and ask for general hypersensitivity reaction (skin rash), cardiomyopathy, neurological changes including sensory changes, renal function impairment or thyroid dysfunction which may occur in cobalt intoxication. To optimize the diagnostic histological investigations using the Krenn classification are extremely helpful.

About the authors

M. Thomsen

Mittelbaden Clinics Baden-Baden, Trauma and Orthopaedic Surgery Units

Author for correspondence.
Russian Federation

V. Krenn

Center for Histology, Cytology and Molecular Diagnostics

Russian Federation

P. Thomas

Hospital and Outpatients’ Clinic for Dermatology and Allergology, Ludwig Maximilian University

Russian Federation

J. P. Kretzer

Laboratory of Biomechanics and Implant Research, University of Heidelberg, Department of Orthopaedics

Russian Federation


  1. Bergschmidt P, Bader R, Mittelmeier W. Metal hypersensitivity in total knee arthroplasty: revision surgery using a ceramic femoral component - a case report. Knee. 2012;19(2):144-147.
  2. Gao X, He RX, Yan SG, Wu LD. Dermatitis associated with chromium following total knee arthroplasty. J. Arthroplasty. 2011; 26(4):665.
  3. Gustafson K, Jakobsen SS, Lorenzen ND. et al. Metal release and metal allergy after total hip replacement with resurfacing versus conventional hybrid prosthesis. Acta Orthop. 2014; 16:1-7.
  4. Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopaedic implants. J. Bone Joint Surg. Am. 2001; 83-A(3):428-436.
  5. Hart AJ, Sabah S, Henckel J. et al. The painful metal-on-metal hip resurfacing. J. Bone Joint Surg. Br. 2009; 91(6):738-744.
  6. Jones DA, Lucas HK, O´Driscoll, Price CH, Wibberley B. Cobalt toxicity after McKee hip arthroplasty. J. Bone Joint Surg. Br. 1975; 57:289-296.
  7. Krenn V, Morawietz L, Kienapfel H. et al. Revised consensus classification. Histopathological classification of diseases associated with joint endoprostheses. Rheumatol. 2013;72(4):383-392
  8. Lützner J, Hartmann A, Dinnebier G, Spornraft-Ragaller P, Hamann C, Kirschner S. Metal hypersensitivity and metal ion levels in patients with coated or uncoated total knee arthroplasty: a randomised controlled study. Int. Orthop. 2013; 37(10):1925-1931.
  9. Mahendra G, Pandit H, Kliskey K, Murray D, Gill HS, Athanasou N. Necrotic and inflammatory changes in metal- on-metal resurfacing hip arthroplasties. Acta Orthop. 2009 Dec;80(6):653-9.
  10. McMaster WC, Patel J. Adverse tissue reaction response lesion of the knee associated with morse taper corrosion. J. Arthoplasty. 2013; 28(2) 375-381.
  11. Morlock MM, Bishop N, Zustin J. et al. Modes of implant failure after hip resurfacing: morphological and wear analysis of 267 retrieval specimens. J. Bone Joint Surg. Am. 2008; 90(3):89-95.
  12. Niki Y, Matsumoto H, Otani T, Yatabe T, Kondo M, Yoshimine F, Toyama Y. Screening for symptomatic metal sensitivity: a prospective study of 92 patients undergoing total knee arthroplasty. Biomaterials. 2005;26(9):1019-1026.
  13. Oldenburg M, Wegner R, Bauer X. Severe cobalt intoxication due to prosthesis wear in repeated hip arthroplasty. J. Arthroplasty. 2009; 24:15-20.
  14. Pazzaglia UE, Apostoli P, Congiu T, Catalani S, Marchese M, Zarattini G. Cobalt, chromium and molybdenum ions kinetics in the human body: data gained from a total hip replacement with massive third body wear of the head and neuropathy by cobalt intoxication. Arch Orthop Trauma Surg. 2011; 131(9):1299-1308.
  15. Rizzetti MC, Liberini P, Zarattini G, Catalani S, Pazzaglia UE, Apostoli P. et al. Loss of sight and sound. Could it bet the hip ? Lancet. 2009; 373:1052-1053.
  16. Steens W, Loehr JF, von Foerster G, Katzer A. Chronic cobalt poisoning in endoprothetic replacement. Orthopäde. 2006; 35(8): 860-864.
  17. Thakur RR, Ast MP, McGraw M, Bostrom MP, Rodriguez JA, Parks ML. Severe persistent synovitis after cobalt-chromium total knee arthroplasty requiring revision. Orthopedics. 2013; 36(4):e520-524.
  18. Thomas P, Stauner K, Schraml A, Mahler V, Banke IJ, Gollwitzer H. et al. Characteristics of 200 patients with suspected implant allergy compared to 100 symptom-free arthroplasty patients. Orthopäde. 2013; 42(8):607-613.
  19. Thomsen M, Rozak M, Thomas P. Pain in a chromium- allergic patient with total knee arthroplasty: disappearance of symptoms after revision with a special surface-coated TKA a case report. Acta Orthop. 2011; 82(3): 386-388.
  20. Thomsen M, Kretzer JP, Krenn V, Thomas P. Different symptoms in patients with prostheses with metal-metal bearings. Orthopäde. 2013; 42(8):637-642
  21. Thomsen M, Rozak M, Thomas P. Use of allergy implants in Germany: results of a survey. Orthopäde. 2013; 42(8):597-601.
  22. Thyssen J P, Jakobsen S S, Engkilde K, Johansen J D, Soballe K, Menne T. The association between metal allergy, total hip arthroplasty, and revision. Acta Orthop. 2009; 80(6): 646-652.
  23. Tower SS. Arthroprosthetic cobaltism associated with metal on metal hip implants. BMJ. 2012; 344:e430.

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