Article Title

PHACT vs. Fiction




Introduction and objective: Prosthetic hip-associated cobalt toxicity (PHACT) is a rare cause of cobalt toxicity from metal-on metal (MoM) total hip prosthesis. There are few reports of PHACT and only one case report from our review that reported tremor as a presenting symptom (7).

Case presentation: This is a report of a 44 year old male with history of hip replacement. He presented to PCP with progressive worsening of muscle weakness, fatigue and tremor of two months duration. After an extensive work up was performed and reviewing current literature, serum cobalt level was eventually performed and was found to be high. Resolution of the symptoms with concomitant decrease in serum cobalt was noted.

Discussion: PHACT being a diagnosis which is rare and done by exclusion, it is important to make it a part of the differential diagnosis. As our patient also has the diagnosis of Charcot Marie Tooth, it is important to prevent anchoring heuristic bias and evaluate the patient from fresh eyes especially with a history of MoM device placement.

Conclusion: The symptoms did resolve on removing the MoM device which does imply that PHACT can be regarded closer to a fact when compared to a fiction.

Conflict(s) of Interest

All Authors have no conflict of interest to disclose.

References with DOI

1. Devlin JJ, Pomerleau AC. Clinical features, testing, and management of patients with suspected prosthetic hip-associated cobalt toxicity: a systematic review of cases J Med Toxicol. https://doi.org/10.1007/s13181-013-0320-0

2. Tower SS. Arthroprosthetic cobaltism: identification of the at-risk patient. Alaska Med 2010

3. ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/ucm241744.htm.

4. Moyer TP, Sierra R. Mayo medical laboratories. Evaluation of metal-on-metal wear of orthopedic implants- role of serum chromium and cobalt analysis.

5. The United States Food and Drug Administration information on soft tissue imaging and metal ion testing.

6. S Catalani, MC Rizzetti, A Padovani and P Apostoli, Neurotoxicity of cobalt. Human and Experimental Toxicology 31(5) 421-437. 2012 https://doi.org/10.1177/0960327111414280

7. SS Tower. Arthroprosthetic cobaltism: neurological and cardiac manifestations in two patients with metal- on-metal arthroplasty. J Bone Joint Sur. 2010 https://doi.org/10.2106/jbjs.j.00125

8. Morin Y, Daniel P. Quebec beer-drinkers’ cardiomyopathy: etiological considerations. Can Med Assoc J. 1967; 97(15): 926-928.

9. Louis ED, Ottman R, Hauser WA. How common is the most common adult movement disorder? Estimates of the prevalence of essential tremor throughout the world. Movement Disorder. 1998. https://doi.org/10.1002/mds.870130105

10. Nikolopoulos D, Michos I, Patsouris E, Theocharis S (2012) Local and systemic toxicity of nanoscale debris particles intotal hip arthroplasty. J App Toxicol 32:255–2694034. https://doi.org/10.1002/jat.2729

11. Alexanderssen R (1988) Blood and urinary concentrations as estimators of cobalt exposure. Acrh Environ Health 43(4):29–30335. https://doi.org/10.1080/00039896.1988.10545953

12. Devitt BM, Queally JM, Vioreanu M, Butler JS, Murray D, DoranP, O'Byrne JM (2010) Cobalt ions induce chemokine secretion in avariety of systemic cell lines. Acta Orthop 81(6):756–76436. Simonsen LO, Harbak https://doi.org/10.3109/17453674.2010.537806

13. Charcot–Marie–Tooth disease type 1A with 17p11.2 duplication. Clinical and electrophysiological phenotype study and factors influencing disease severity in 119 cases. Nazha Birouk,1 Riadh Gouider,1 Eric Le Guern,2 Michel Gugenheim,1 Sandrine Tardieu,2 Thierry Maisonobe,1 Nadine Le Forestier,1 Yves Agid,2 Alexis Brice2 and Pierre Bouche1

14. Evidence against implant-derived cobalt toxicity: Case report and retrospective study of serum cobalt concentrations in an orthopedic implant population. Nicole V. Tolana, Rafael J. Sierrab, and Thomas P. Moyera.Hip Int. 2014 Dec 5; 24(6):568-74. doi: 10.5301/hipint.5000179. Epub 2014 Jul 31. https://doi.org/10.1016/j.clinbiochem.2014.10.012

15. Self-reported neurological clinical manifestations of metal toxicity in metal-on-metal hip arthroplasty. Van Lingen CP1, Ettema HB, Van Der Straeten C, Kollen BJ, Verheyen CC. Can J Cardiol. 2014 Apr; 30(4):465.e13. https://doi.org/10.5301/hipint.5000179

16. The United States Food and Drug Administration (2013) information for all health care professionals who provide treatment to patients with a metal-on-metal hip implant. Released January 17, 2013. http://www.fda.gov/MedicalDevices/