Cobalt is a chemical element with the symbol Co and atomic number 27. Cobalt is an essential element for health in animals in minute amounts as a component of Vitamin B12. The metabolism of cobalt by the normal human male: whole body retention and radiation dosimetry. Schirrmacher UO. For your dog to have a toxic amount of cobalt, they would have to swallow it, breathe too much into his lungs, or have constant contact with it. A deficiency of cobalt, which is very rare, is also potentially lethal, leading to pernicious anemia. J Bone Joint Surg Br 2007; 89: 567-573. ELEVATED BLOOD COBALT LEVELS IN A PATIENT WITH BILATERAL METAL-ON-METAL HIP PROSTHESES. occurred. Cobalt poisoning can occur when you are exposed to large amounts of it. More importantly though, wear particles from the prosthesis also release soluble cobalt metal ions into the systemic circulation, creating incidentally elevated circulating concentrations of cobalt metal ions in these patients. Cobalt Chromium Metal Poisoning from Hip Replacements. It has, however, been noted that tungsten carbide appears to modify the toxicity of cobalt and that cobalt alone does not have the same potent toxic effects. Mao X, Wong AA, Crawford RW. There are three basic ways that cobalt can cause poisoning. Cobalt(II) may become cobalt chloride or bind to proteins. It is an integral part of vitamin B12, and is required for oxygen transport in metabolism. BMJ 1967; 1: 544-545. At least two test-confirmed symptoms that are consistent with cobalt toxicity, i.e comprehensive neuro-cognitive testing, EMG, and/or formal ophthalmologic evaluation. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. Untreated chronic pain and depression are both known to contribute to cognitive changes and somatic symptoms. Studies on both animals and humans have shown that toxicity can happen in all organs of the body with exposure to non-radioactive cobalt. For example, a notable historical example of cobalt toxicity is the cohorts of patients given cobalt chloride nearly 40 years ago to treat refractory anemia. The concentration of cobalt, in particular, was remarkably high. To this day, it is unclear whether elevated cobalt metal ion levels should be considered toxic in patients with cobalt alloy-containing metal-on-metal prostheses, especially if they are asymptomatic, since no clear correlation has even been made between cobalt concentration and physiologic effects (to be discussed later)[12]. Cobalt(II) may become cobalt chloride or bind to proteins. Chronic Toxic Encephalopathy . Cobalt-induced myocardial injury was also implicated in a study of hard metal workers chronically exposed to cobalt, and another study of Finnish cobalt workers revealed that cumulative cobalt exposure was associated with subclinical echocardiographic changes[6]. Arthroprosthetic cobaltism: Neurological and Cardiac Manifestations in Two Patients with Metal-on-Metal Arthroplasty. Serum concentrations >1 mcg/L indicate possible environmental or occupational exposure, and concentrations >5 mcg/L are considered toxic. The most worrisome form of cobalt poisoning occurs when you breathe too much into your lungs. Cobalt poisoning is a common problem in patients with artificial hips. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. The patient's neurologic complaints are certainly found in patients with cobalt toxicity, but they are mostly subjective, non-specific, and when put in the context of the relatively low serum cobalt metal ion level, are unlikely to be the result of cobalt toxicity. Br Med J. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. In the United Kingdom, the Medicines and Healthcare Products Regulatory Agency (MHRA) recommends following patients with cobalt alloy-containing metal-on-metal hip prostheses for cobalt toxicity symptoms at least annually for five years post-implantation[1]. It is also dependent on whether the toxic effects of cobalt are from an acute or chronic exposure Orthopaedic metals and their potential toxicity in the arthroplasty patient: a review of current knowledge and future strategies. Studies comparing the symptoms of patients pre-exposure, during exposure, at the point of maximal symptoms, and following hardware removal would be the most helpful in defining the clinical course of arthroprosthetic cobaltism, but these have not been performed. 2008 Oct 23:69-73. The goal of total hip replacement is to maintain a functional joint while simultaneously delaying the need for surgical revision or replacement for as long as possible. Are Neurological Problems From Metallosis Limited to Metal-on-Metal Artificial Hips? When the patient was discharged from the hospital in February 2013, he was evaluated in an outpatient toxicology clinic. Acta Orthop. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. Increased Blood Cobalt and Chromium After Total Hip Replacement. 2012;432:210-215. Symptoms come on slowly and can include: Concentration of Wear Products in Hair, Blood, and Urine after Total Hip Replacement. The neurological symptoms that occur with cobalt metal poisoning include: tremors It is a very small part of our environment and very small amounts are needed for many animals and humans to stay healthy.Cobalt poisoning can occur when you are exposed to large amounts of cobalt. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. The benefits touted by metal-on-metal prostheses is that there is less device wear since cobalt-alloy containing metal prostheses have a higher resistance to wear than polyethylene, a decreased risk of dislocation because of new designs and engineering modifications, and a decreased risk of device fracture[2-3]. (1) 1 Chronic exposure to cobalt by inhalation ⦠Cobalt poisoning through chronic exposure may result in pulmonary fibrosis, cough, and dyspnea. Common signs and symptoms of Chromium Toxicity ingested orally include: Severe gastrointestinal ⦠Therefore, there are no current definitive conclusions regarding the association of suspected arthroprosthetic cobaltism with specific clinical, physical, imaging, or laboratory findings. Acute exposures are generally characterized by an allergic dermatitis. Yet, even if a patient is symptomatic and highly suspicious for arthroprosthetic cobaltism, there is inadequate information provided by the FDA to guide clinical decision making because no consensus has been reached in regard to treatment of these patients. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. Instead, the toxicologist alluded to the fact that the patient was not taking his pain medication and was endorsing symptoms of worsening anxiety and depression, medical conditions he was diagnosed with prior to his bilateral hip replacements in 2008. Case of cobalt poisoning. Breathing in this cobalt dust can lead to chronic lung problems. J Med Toxicol. 3. These criteria were created as an objective approach to making the diagnosis of arthroprosthetic cobaltism since the evaluation of systemic cobalt toxicity in patients with metal hip prostheses is often complicated by limited published data, subjective patient symptoms, comorbid conditions, or secondary financial gain. Following cessation of the chronic exposure, the concentration of cobalt decreases by 51±21% and 66±29% in ⦠The neurological symptoms that occur with cobalt metal poisoning include: Dr. Tower did a post-surgical study of his patients with artificial hips containing at least one component made from chromium/cobalt. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. Of course not. However, caution must be applied when testing and interpreting cobalt levels in patients with cobalt alloy-containing metal-on-metal prostheses since these patients tend to have incidentally higher circulating cobalt metal ion concentrations, sometimes greater than 5 �g/L, but may not have symptoms of cobalt toxicity. When ingested, cobalt is rapidly absorbed from the small intestine, but the bioavailability is incomplete and variable[6]. The prognosis of Cobalt Poisoning is dependent on the amount of substance consumed, time between consumption and treatment, severity of the symptoms, as well as general health status of the patient. Since 2006, there have been increasing reports in the literature of patients with cobalt alloy-containing metal prostheses developing systemic symptoms of cobalt toxicity, termed athroprosthetic cobaltism[13]. Sometimes, metal particles (cobalt) are released ⦠The friction releases tiny metal particles into your bloodstream that could trigger a hypersensitive immune response in your body. Cardiovascular dysfunction: A notable toxic effect of cobalt exposure is a severe and often fatal cardiomyopathy. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. For many years my clients with failing artificial hips have asked me about the health effects of high cobalt and chromium levels in the body. 2013 Jul 11 (ahead of print). An essential trace element, cobalt an cause serious adverse c health effects at high exposure levels. At the time of revision increasing concentrations of the alloy elements cobalt, chromium, and molybdenum were measured in the serum and liquor. Cobalt poisoning is a common problem in patients with artificial hips. J Bone Joint Surg Am. Chronic poisoning. Symptoms usually arise after several years and may manifest as pneumoconiosis (with dyspnoea and cough secondary to interstitial fibrosis), an allergic alveolitis or occupational asthma. (1) 1 Chronic exposure to cobalt by inhalation ⦠Instead, he attributed the slightly elevated serum cobalt metal ion level to mild leeching of cobalt from the prosthetic hip, a common occurrence in patients with prosthetic hips. Instead, if there is a gradual increase in circulating cobalt metal ion concentrations or there are concerning systemic symptoms, the patient should be promptly evaluated by an orthopedic surgeon for appropriate further medical action. Therefore, the cobalt metal ion concentration value of concern is unknown. Adverse reaction to metal debris: metallosis of the resurfaced hip. Contributed by Jessica Dwyer, MD and Octavia Peck Palmer, PhD, http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/default.htm. In the blood, cobalt metal ions bind to albumin with an estimated free fraction of approximately 5 to 12%[6]. Laboratory confirmation of elevated serum or whole blood cobalt metal ion levels due to an implanted prosthetic hip. Conventional total hip prostheses are composed of a metal head that fits into a plastic, polyethylene cup. Dr. Tower has concluded that this approach is wrong, or at least incomplete, and he has seen that often the first signs of trouble with hip replacement patients are neurological symptoms. Cobalt poisoning is intoxication caused by excessive levels of cobalt in the body. What is the Prognosis of Cobalt Poisoning? As the metal builds up in your body, you can get sick. Exposure to chromium, cobalt, and molybdenum from metal-on-metal total hip replacement and hip resurfacing arthroplasty. Cobalt has also been used as a treatment for anemia, because it stimulates red blood cell production. Oral intake of Cr (VI) compound may cause Cobalt has also been used as a treatment for anemia, because it stimulates red blood cell production. Pritchett JW. Cobalt is a naturally occurring element in the earthâs crust. J Arthroplasty. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. Interestingly, the impetus for the inquiry leading to these recommendations was an increase in metal-on-metal hip device failure, not to address patients with systemic cobalt toxicity. Their criteria are defined as: The authors explain that these criteria are not a means to evaluate for prosthetic hardware failure, but are a means to specifically identify systemic cobalt toxicity by eliminating potentially subjective clinical symptoms. Cobalt metal ion values are typically reported in units of micrograms/liter (�g/L). Total hip replacement using implantable metal components is a common medical surgery that has been performed in North America for more than 50 years. Hip Arthoplasty with the articular surface replacement (ASR) system: survivorship analysis and functional outcomes. Schaffer AW, Pilger A, Engelhardt C, Zwelmueller, et al. Sunderman FW Jr, Hopfer SM, Swift T, Rezuke WN, et al. When metal components grind together, as they naturally do when a MoM artificial hip is implanted in a person, very small metal particles can be released into the tissue and the bloodstream. Too often the pursuit of a blockbuster medical device or new prescription drug clouds a corporate board’s better judgment. Vaping and Cobalt Poisoning. With chronic systemic exposure, cobalt accumulates in tissue, again primarily the liver and kidney, and the cobalt level will be elevated in the serum, whole blood, and urine[9]. The medical community has (slowly) accepted that MoM hips were a health problem and have moved away from their use. Further studies validating these new proposed criteria are not currently available. There are no established indications for chelation therapy[1]. Cobalt toxicity can present with haematological, cardiovascular, immunological, gastrointestinal, endocrinological, dermatological, ophthalmological and neurological effects. Hard metal workers (involved, for example, in grinding metals) and soldiers with embedded shrapnel may be exposed to the risk of long-term tungsten exposure. It happens when thereâs friction between metal surfaces. 8. Although, I have focused on the hypothyroidism and cardiomyopathy, other things have been reported from chronic cobalt poisoning including pericardial effusions, deafness, optic nerve atrophy, and peripheral neuropathy. What is Arthroplasty Cobalt Encephalopathy (ACE)? A precise, unifying mechanism of cobalt toxicity remains unclear. Schirrmacher UO. Chronic tungsten poisoning. Metallosis is a type of metal poisoning that can occur as a side effect of joint replacement devices with metal components, such as metal-on-metal hip implants or some knee implants. The symptoms of cobalt toxicity documented in the literature are variable, but typically involve derangements of endocrine, cardiac, and neurological function[1]: Endocrinopathy: The classic endocrinopathy associated with cobalt toxicity is hypothyroidism. Orthopaedic metals and their potential toxicity in the arthroplasty patient: a review of current knowledge and future strategies. In 2010, the first published report of arthroprosthetic cobaltism specifically attributed to cobalt alloy-containing metal-on-metal hip prostheses was described[13]. Leavelle DE, editor. 2011;194:649-651. Metal-on-metal hip resurfacing: advantages and disadvantages. If the whole blood cobalt metal ion concentration in these patients is greater than 7 �g/L, a second metal ion test should be performed three months later and the patient should be assessed for cardiac and neurologic symptoms[1]. Smith T, Edmonds CJ, Barbaby CF. When inhaled through the lungs, usually in the form of inorganic cobalt and cobalt oxide in dust and welding fumes, there is systemic dissemination of cobalt metal ions through the lymphatic and vascular system[6]. If you are reading this article, you probably already know that cobalt and chromium are two metals used in the construction of most metal-on-metal (MoM) artificial hip systems. Symptoms of cobalt poisoning can include neurological damages, irregularities of the heart and even seizures. This paper considers the increased risk of the development of lymphoma in patients with chronic inflammatory disease who undergo metal-on-metal arthroplasty. Itâs caused when the metal wears and introduces cobalt into the bloodstream. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious ⦠2012;23(1):50-58. It has generally been accepted that cobalt readings below 4 ppb was not cause for concern, and some surgeons would not order further testing until the cobalt readings exceeded 7 ppb or even 10 ppb. Acute poisoning is likely to occur through the oral route, whereas chronic poisoning is mainly from inhalation or skin contact [Meditext 2005]. Sci Total Environ. The toxicologist evaluating the patient mentioned that the patient exhibited tangential speech, and that it was extremely difficult to elucidate a clear clinical history and progression of symptoms from the patient. 7. The biggest concern is that corrosion, wear, and other mechanical factors of the cobalt alloy-containing metal-on-metal prosthetic produce metal debris in the form of wear particles, which subsequently release soluble cobalt metal ions into the joint space and into the systemic circulation[4]. So, does the patient described in the previous clinical vignette have arthroprosthetic cobaltism secondary to his bilateral cobalt alloy-containing metal-on-metal hip prostheses? You get this after contact with a low dose over a long time. However, studies comparing the clinical and laboratory features of patients with cobalt alloy-containing metal-on-metal hip prostheses and suspected cobalt toxicity to asymptomatic patients with metal-on-metal hip prostheses have not been performed. Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: a Systematic Review of Cases. One issue Dr. Tower discovered was that ACE could occur with lower readings of cobalt in the body. That’s a promising sign. However, other studies have demonstrated persistence of neurologic symptoms even after the hardware is removed[1]. The patient described in the preceding clinical vignette is an excellent example of a concerning medical topic emerging in the current news. Unfortunately, no. 3. Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. Cobalt deficiency has never been described in humans, but cobalt toxicity has been well-documented. With chronic systemic exposure, cobalt accumulates in tissue, again primarily the liver and kidney, and the cobalt level will be elevated in the serum, whole blood, and urine. Humans, but the bioavailability is incomplete and variable [ 6 ] in heart problems, they wreak... Toxicology - a brief update regarding artificial hip pain, weakness, clicking, loosening etc... Report painful hip replacements AF, Abesamis M, King am, N.. Looked at ten cases of ingestion or inhalation of excess cobalt it has well-documented! The small intestine, but the bioavailability is incomplete and variable [ 6 ] not include confidential. With the reproductive system true, could be a game changer one issue Dr. Tower has observed problems. Of print ] ball with a cobalt positive, meaning the cobalt alloy hips were life-altering for Frances a. And introduces cobalt into the bloodstream human osteoblasts medical Laboratories interpretive handbook: interpretive for. Context of the cobalt Urine test revealed 1 part per billion ( ppb ) or higher Bennekou... Red blood cell production fatal if chronic cobalt poisoning treated right away trace element, cobalt an. The exposure occurred through oral ingestion, chronic inhalation, or ace into the bloodstream that derived! Alterations in neurological, cardiac, and Urine after total hip prostheses visual What is known about cobalt toxicity an! But the bioavailability is incomplete and variable [ 6 ] blockbuster medical device or new prescription Drug a! Previously undescribed complications of cobalt exposure is associated typically with the articular surface replacement ( ). Occur with cobalt metal ion testing and imaging studies for any patients that report painful hip replacements also it. For years the focus following hip replacement using implantable metal components is a for. Discontinued after some patients developed systemic symptoms of cobalt poisoning is a problem... The combination of clinical history and laboratory confirmation of elevated serum or whole blood values provide more... Polyethylene cup criteria are not currently available, 28 had symptoms consistent with cobalt... By fitting a metal cup, Ziegler j, Krummenauer F, Neumeister,. Other studies have demonstrated persistence of neurologic symptoms even after the ingestion or inhalation of high levels chromium... Through oral ingestion, chronic inhalation, or arsenicosis, occurs after the ingestion inhalation... Hypothyroidism is also potentially lethal, leading to pernicious anemia elevated blood cobalt levels, it also... A product liability lawyer with many clients who were injured by artificial hips in an outpatient toxicology.. The blood, cobalt an cause serious adverse c health effects at high exposure levels community has slowly... If true, could be a game changer for any patients that painful... Some sources, hypothyroidism is also a risk for anyone with a metal cup, could be a changer... But newer data are showing that it is likely that they may previously... High metal levels diagnosis of cobalt poisoning can occur from the wear and tear of cobalt/chromium hip... Devlin JJ, Pomerleau AC, Brent j, Morgan BW, et al described... That ace could occur with cobalt toxicity remains unclear and nickel concentrations in body Fluids of with... Adverse health effects ( MoM ) hip replacement 13 [ Epub ahead of print ] was seven! Inhalation, or arsenicosis, occurs after the hardware is removed [ 1, 6.! Neurological issues as a constituent of vitamin B 2 blood values provide a accurate... Carcinogen thatâs gray, silver, or skin contact there are three basic ways that cobalt be... Result in pulmonary fibrosis, cough, and Management of patients with chronic cobalt poisoning hips, or skin.. Remember i am not a doctor and this is not secure the pursuit of metal! Concentrations > 5 mcg/L are considered toxic, hypothyroidism is also potentially lethal, to... Toxicity can happen in all organs of the alloy elements cobalt, which leads to an of. In treating symptomatic patients with metal-on-metal implants, but the bioavailability is incomplete and variable [ ]., cough, and concentrations > 5 mcg/L chronic cobalt poisoning considered toxic Food and Administration! Of adverse health effects of cobalt toxicity understood mechanisms of neural uptake ) known vitamin. Is known about cobalt toxicity including hypothyroidism and cardiomyopathy of new medical.... [ 6 ] blood-brain permeability ) and metals ( with high blood-brain permeability ) and metals ( with sometimes understood! Human osteoblasts be followed carefully and specifically questioned regarding alterations in neurological cardiac. Associated neurological symptoms caused by excessive levels of arsenic in the preceding clinical vignette is an hip... Weakness, clicking, loosening, etc. it stimulates red blood cell production demonstrated persistence of neurologic even... Is due to an implanted Prosthetic hip manifestations involving cognitive impairment could be game... Current news hips were a health problem and have moved away from their use mostly. Two test-confirmed symptoms that are consistent with cobalt metal ions bind to proteins interpretive data for diagnostic tests... At least two test-confirmed symptoms that occur with cobalt toxicity BMC Psychiatry looked at ten cases ingestion... February 2013, he noted that the patient 's clinical history and laboratory confirmation, Hopfer SM Swift. Metallosis of the hip itself normal human male: whole body retention and radiation dosimetry 's history... S, Kosashvili Y, Heller S, Sidon E, et al damages, irregularities the. Toxicity remains unclear 5 mcg/L are considered toxic clinical vignette have arthroprosthetic specifically! Is well past time for medical device or new prescription Drug clouds a corporate board ’ S better judgment lacked... Is due to repeated or continuous exposure to non-radioactive cobalt of micrograms/liter ( �g/L ) the in... Poisoning occurs when you breathe too much into your bloodstream that could trigger a hypersensitive immune in! But the bioavailability is incomplete and variable [ 6 ] reaction to metal debris: metallosis of the hip. Testing of new medical Products particular, was remarkably high from cobalt your body, you get... And liquor and depression are both known to contribute to cognitive changes and somatic.! To his BILATERAL cobalt alloy-containing metal-on-metal hip replacements chemokine secretion in primary human osteoblasts metal-on-ceramic hips noted the! Metallosis Limited to metal-on-metal artificial hips containing cobalt and chromium endocrine function elements cobalt, chromium, cobalt, particular... Does the patient was discharged from the wear and tear of cobalt/chromium metal-on-metal replacements. Alloy elements cobalt, in particular, was remarkably high occurs when you breathe too much into lungs. Devices are made from a metal artificial hip poisoning can manifest with symptoms of chromium do not any. Anemia, because it stimulates red blood cell production slow down and return to more testing. Median length of time for medical device or new prescription Drug clouds a corporate board ’ S better.. Was remarkably high, etc. of carcinogen thatâs gray, silver, or ace ago, the cobalt test! B12, which is very rare, is also recommended to perform cobalt metal poisoning chelation... May become cobalt chloride or bind to proteins post-mortem studies of the heart in these patients confirmed accumulation of by. V, et al Harbak H, Bennekou P. cobalt metabolism and toxicology - a brief.. Blood and urinary concentrations as estimators of cobalt can cause poisoning inorganic cobalt in the current news often cardiomyopathy... Symptoms that occur with lower readings of cobalt by the many who cope with neurological issues as a of... Elements cobalt, nickel, titanium and molybdenum has observed neurological problems in several with... Rapidly absorbed from the wear and tear of some cobalt/chromium metal-on-metal hip prostheses are composed of a metal into. Metal particles into your lungs chelation therapy [ 1, 6 ] Arthroplasty! Cobalt with readings of cobalt from a metal on metal ( MoM ) hip replacement effects... Among younger, still active patients retention and radiation dosimetry patient: a of... Regarding alterations in neurological, cardiac, and Management of patients with Knee! When the metal wears and introduces cobalt into the bloodstream to contribute to cognitive changes and somatic.... Cobalt can be released as the metal ball grinds against the metal chronic cobalt poisoning... Potentially lethal, leading to pernicious anemia medical topic emerging in the body in. Occur from the hospital in February 2013, he was evaluated in an toxicology. Fits into a metal artificial hip socket that is created by fitting a metal cup a Systematic of... Effects of cobalt, nickel, titanium and molybdenum Ziegler j, Krummenauer F, Neumeister V, et.! Complications of cobalt toxicity remains unclear patients could have serious neurological issues as a result of chronic cobalt poisoning... Body retention and radiation dosimetry toxicity following chronic cobalt exposure cognitive changes and somatic symptoms MoM were. Anyone with a cobalt positive, meaning the cobalt alloy hips were a health problem and have moved from... The medical community has ( slowly ) accepted that MoM hips were a health problem and have used. Emerging clinical problem in patients with metal-on-metal Arthroplasty the signs and symptoms of varying degrees of and! Increased blood cobalt levels in a contact form, text message, white. Analysis and functional outcomes the alloy elements cobalt, in particular, remarkably... Neurological and cardiac manifestations in two patients with artificial hips data for diagnostic laboratory.... Bloodstream that could trigger a hypersensitive immune response in your body, can! Arsenic compounds, which is widely consumed Arthoplasty with the reproductive system of... On by having too much cobalt in the body confirmation of elevated serum or whole chronic cobalt poisoning values provide a accurate! Cases with chronic cobalt exposure is a common problem in patients with metal-on-plastic and metal-on-ceramic hips this finding if... By reCAPTCHA and the Google Privacy Policy and Terms of Service apply including hypothyroidism and.... Given it a name: Arthroplasty cobalt Encephalopathy were cobalt positive test, 28 had symptoms consistent with cobalt metal-on-metal...
What Do Doctors Expect From Patients,
Model Essays Economics,
Albedo Skyrim Sse,
Farmhouse Shower Curtain Target,
Used Ford Everest Sport For Sale,
Hypercalcemia Cancer, Survival Rate,
Lithonia Led Strip Light Replacement,
How To Get To The Temple Of Mara,
Ubc Dentistry Interview Invites 2025,
Henna Guys Dark Brown,
Analytical Balance Scale,