Ask the doctor: My hip operation has left metal in my blood

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My surgeon has informed me my two hip replacements were ‘metal-on-metal’ devices, and recent reports have suggested these may leak tiny amounts of metal into the body. Blood tests revealed I have 100 times more than normal the amount of cobalt in my blood, as well as dangerous amounts of chromium. I have no pain, and my surgeon said they’ll monitor me with yearly samples. With such high levels is this delay justified? I wonder if I should press for revision surgery. Robert Peters, Cardiff. There is concern that cobalt toxicity is under recognised

What an anxious time for you, and how alarming to receive such news.

Before I explain your options, let me provide some background to your predicament.

First, let me stress that replacement of the hip joint — usually on account of severe osteoarthritis or after a fracture — is usually successful.

The hip joint is a so-called ball and socket joint, and the conventional type of replacement uses a metal head (the ball) fitting into a plastic cup (the socket).

However, there are concerns about the extent of wear on the plastic over time, which may lead to the need for further — or ‘revision’ — surgery.

This is a complex procedure and one that’s best avoided.

Because of this, attempts have been made to reduce the wear by making both the head and cup metal, specifically a stainless steel alloy which contains cobalt and chromium.

However some types of ‘metal-on-metal’ replacements have not lived up to the promise, and may wear or come loose — this leads to minute particles of metal leaching into the soft tissues around the joint.

This reaction, known as metallosis, may cause inflammation and discomfort.

Furthermore, as you have found, this can also lead to higher levels of cobalt and chromium throughout the body, dispersed via the bloodstream and lymph system.

Increased cobalt levels have been linked to symptoms such as tremor, poor coordination, cognitive decline and depression.

There have also been reports of damaging effects on the heart, hearing and vision.

The possible relationship between these symptoms and chromium levels is not proven, and it’s not clear whether all patients experience these effects.

Still, there is concern that cobalt toxicity is under recognised.

In the expectation of learning more about this, the British Hip Society recommends regular follow-up of patients with metal-on-metal replacements for at least five years.

The Medicines and Healthcare products Regulatory Agency is monitoring the situation with orthopaedic advisers.

From the evidence available, there is a low risk of complications. But if pain develops, further investigations are necessary.

If the joint has loosened, then revision surgery becomes essential.

There have been some studies on patients who have had very high cobalt levels in their blood, and who have had the ‘cup’ part of the artificial joint replaced with plastic or ceramic.

Their side-effects from metal toxicity improved, and the level of metal in their bloodstream was lowered.

CONTACT DR SCURR

To contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email drmartin@dailymail.co.uk — including contact details.Dr Scurr cannot enter into personal correspondence.His replies cannot apply to individual cases and should be taken in a general context.Always consult your own GP with any health worries.

But what is unclear is how to treat patients such as yourself, who have high blood levels of cobalt and chromium but are not experiencing pain.

There is still the potential problem of toxicity, but the level at which these metal particles cause a problem varies widely from person to person.

Other symptoms of metal poisoning are dizziness and skin rashes.

But the problem is that these symptoms, in addition to those listed above, can occur for many other reasons.

The rule in medicine is, generally, to treat the patient and the symptoms, and not the blood test results.

Your treatment, therefore, must depend upon whether you are displaying any symptoms, and then a careful, balanced judgement must be made.

Although I understand this is a worrying time for you — and in a sense you are between the Devil and the deep blue sea — please remember revision surgery does carry its own risks, and it may not be wise to push for this on the evidence of blood levels alone.

Making an association between any untoward health events and the possibility of metal toxicity is far from straightforward and does need the most careful balanced judgement.

Another meeting with your specialist to discuss these options may be a good idea, and if you start to experience any pain, then certainly do make another appointment.

My wife has regular flare-ups of very painful gout. She has been prescribed a range of drug treatments, but the flare-ups continue. Is it possible to reduce gout attacks by changing one’s diet?Mr G. Bennett, Barking, Essex.

The poor lady. Gout is an exquisitely painful type of arthritis. It develops from a build-up of a compound called uric acid which is produced when we break down chemicals called purines.

These are found in foods and are  also produced naturally by the body.

Some people are not able to excrete uric acid efficiently through the kidneys, so levels build up.

However, some can have high levels and do not develop symptoms.

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The risk factors for gout are obesity, high blood pressure, injuries (including surgical operations), alcohol, fasting and eating foods containing large amounts of  purines such as red meat, offal or seafood.

The main treatment to prevent attacks is the medication allopurinol. This must be taken long-term and takes several months to work.

Changing the diet may reduce the frequency of attacks.

As well as the purine-rich foods, your wife needs to exclude beer and spirits, along with foods with high levels of fructose, such as many fruit drinks.

Additionally, certain foods may help lower uric acid levels, although we are unsure exactly how they do this.

These include low-fat dairy products, grains, brown rice and oats.

Coffee may help, as might taking 0.5-1g of vitamin C each day.

A strict long-term dietary regimen that follows these principles may lower levels of uric acid by as much as 15 per cent, though in general, a regular drug treatment is also a good idea.

Do both, in other words, not one or the other.

By the way... Cut 100 cals a day, lose a stone in a year!

When I sat as a member of the Ethics Committee of a new private hospital in West London in 1984, I placed an item on the agenda on many occasions — but it was repeatedly ignored.

I was suggesting this elite flagship should have a no-smoking policy for the entire campus.

But despite the known health hazards, private medical care was meant to be about freedom, said the committee, and if patients, their visitors, or indeed staff chose to smoke, then that was their right.

Looking back, that decision — which culminated in me being sacked from the committee for being a persistent nuisance — seems shocking.

Reducing your intake by 100 calories a day will lead to 0.5kg weight loss in a month, and nearly a stone a year

We would no sooner permit smoking in the hospital building today than serve heroin along with the drinks at the Christmas party.

At last, similar common sense, along with a feeling of determination and urgency, is being applied to the epidemic problem of obesity.

Despite the shock and concern, there’s been insufficient coordination of services and effective action, both at Government level and within the NHS.

The Royal College of Physicians has seized the initiative — as it did with bringing the evidence about the dangers of tobacco use to public awareness 50 years ago.

Its new report, Action On Obesity, recognises that obesity leads to coronary heart disease and diabetes, and increases the chances of some types of cancer.

It makes arthritis worse, interferes with sleep, fertility and the enjoyment of life — and costs the nation a vast amount.

A number of strategies have been proposed, including the appointment of an expert physician in every hospital trust to take charge of the anti-obesity service, better education of GPs in practical techniques (such as how to tell a patient they’re overweight) and the training of specialist nurses.

Most importantly, all healthcare professionals from medics to nurses, physiotherapists, dieticians, even pharmacists, must set an example and all must know the ‘Ten Essential Facts About Obesity’ — such as reducing your intake by 100 calories a day will lead to 0.5kg weight loss in a month, and nearly a stone a year.

All of the ten essential facts are there for anyone to see on the Royal College of Physicians website (rcplondon.ac.uk).

No excuse now!