Resurfacing knee arthroplasty in patients with allergic sensitivity to metals

Metal wear debris generation in primary total knee arthroplasty: is it an issue?

More durable total knee arthroplasties (TKAs) are needed, due to the rising life expectancy, the higher activity levels of patients and the growing concerns about aseptic loosening being caused by metal hypersensitivity. In response, different hypoallergenic metal coatings have been developed for TKAs. However, possible adverse effects of these different metals (cobalt-chromium-molybdenum, zirconium, titanium and tantalum) have been neglected. The aim was to summarize the local and systemic adverse effects (including metal hypersensitivity), survival ratios, patient-reported outcome measures (PROMs) and the plasma metal ion concentrations of the different TKA coatings. A literature search on PubMed and EMBASE was performed. In total, 15 studies were found eligible. Common adverse effects of TKA were infection, loosening, pain, instability and hyper- coagulation disorders. Serious adverse effects related to TKA implants were not reported. The survival ratios and patient-reported outcome measures seem to confirm these good results. In contrast with chromium and cobalt, no significant differences were reported in the nickel, molybdenum and titanium concentrations. No significant differences between the hypoallergenic and standard TKA implants were found in terms of adverse effects, survival ratios and PROMs. A causal relationship between the common adverse effects and the different metals is unlikely. Due to the heterogeneity of the TKA implants used, no firm conclusions could be made. Further research with longer follow-up studies are needed to find possible adverse effects and differences. Thus far, the hypoallergenic implants seem to perform equal to the standard implants.

Morbidity After Metal Allergy to a Total Ankle Implant

Metal allergy to total ankle arthroplasty is rare but can be both an unpredictable and devastating complication. Current literature describing metal allergy in orthopaedics is limited with there being no report to date on metal allergy after total ankle arthroplasty. Our patient underwent a total ankle arthroplasty and developed a diffuse rash 7 weeks postoperatively. The patient then tested positive for a metal allergy and ultimately was converted to an arthrodesis. In the setting of postoperative pain, swelling, erythema, or rash, it is important that metal allergy be on the differential diagnosis. Interestingly, when the patient here underwent allergy testing, only the articulating sides of the implant caused a positive reaction. Thus, allergy testing of both the articular and nonarticular sides of the component is of the utmost importance, as evidenced by the discrepancy found in this case.Levels of Evidence: Level IV: Case report.

The effect of patient-reported metal allergies on the outcomes of shoulder arthroplasty

BACKGROUND

Although literature exists regarding hip and knee arthroplasty outcomes in patients with skin allergy to metals, there is minimal information about skin allergy implications on shoulder arthroplasty outcomes. The purpose of this study was to determine the results, complications, and failure rate among patients with a self-reported metal allergy undergoing shoulder arthroplasty.

METHODS

Fifty-two shoulder arthroplasties were performed at our Institution in 43 patients with self-reported metal allergies. Forty primary and 12 revision shoulder arthroplasties were performed using anatomic (30) and reverse (22) components. Retrospective chart review was performed to determine metal allergy history, implant composition, pain, motion, and complications. Radiographs were reviewed to determine mechanical failure rates. Average follow-up time was 65 months.

RESULTS

Allergies reported included nickel (37), cobalt chrome (4), copper (2), zinc (1), titanium (1), gold (1), and nonspecific metal allergy (8); 8 patients reported multiple metal allergies. All components implanted in patients with nickel allergies contained nickel. At most recent follow-up, pain was rated as none or mild in 88% of shoulders. Active elevation improved from 80° to 141° and external rotation from 24° to 52°. Two revisions were performed for glenoid loosening (3.8%); both were revision cases with substantial glenoid bone loss. One patient with mild pain had a radiographically loose glenoid component 12 years after anatomic shoulder arthroplasty.

CONCLUSION

Results from this study suggest that shoulder arthroplasty in patients with self-reported metal allergy provides satisfactory pain relief and improved range of motion with low revision rates.

Allergy in Total Knee Replacement. Does It Exist?: Review Article

BACKGROUND

There is little data on whether preexisting allergies to implant materials and bone cement have an impact on the outcome of TKA.

QUESTIONS/PURPOSES

This review article analyzes the current literature to evaluate the prevalence and importance of metal and cement allergies for patients undergoing total knee arthroplasty.

METHODS

A review of the literature was performed using the following search criteria: "knee," "arthroplasty," and "allergy" as well as "knee," "arthroplasty," and "hypersensitivity."

RESULTS

One hundred sixteen articles were identified on PubMed, Seventy articles could be excluded by reviewing the title and abstract leaving 46 articles to be included for this review. The majority of the studies cited patch testing as the gold standard for screening and diagnosis of hypersensitivity following TKA. There is consensus that patients with self-reported allergies against metals or bone cement and positive patch test should be treated with hypoallergenic materials or cementless TKA. Treatment options include the following: coated titanium or cobalt-chromium implants, ceramic, or zirconium oxide implants.

CONCLUSION

Allergies against implant materials and bone cement are rare. Patch testing is recommended for patients with self-reported allergies. The use of special implants is recommended for patients with a confirmed allergy.

Revision total knee arthroplasty due to bone cement and metal hypersensitivity

INTRODUCTION

Hypersensitivity to implants is a rare complication of total knee arthroplasty (TKA). Metal and, less frequently, bone cement can produce allergic symptomatology that if unresponsive to conservative treatment could lead to revision.

MATERIALS AND METHODS

We present the case of a patient with generalized pruritus and metal taste starting during the first postoperative month after TKA. Dermal allergy exams revealed that the patient had hypersensitivity to nickel sulphate and cobalt chloride and bone cement. Conservative treatment with antihistamine medication and corticosteroids failed to control the symptoms. The patient underwent revision TKA with a hypoallergic prosthesis 8 months after the primary procedure.

RESULTS

Full disappearance of the symptoms occurred 3 months after revision. The latest follow-up evaluation (3 years post-revision) was unremarkable.

CONCLUSIONS

In our opinion, an exhaustive medical history should be obtained from every candidate for total joint replacement and in cases of prior severe allergic reactions to metals, plastics or glues, patch testing of the components of the future prosthesis should be done. When an already implanted prosthesis causes symptoms like pain, edema, pruritus, erythema, limited range of motion and increase in joint's temperature, the possibility of allergy to metals and/or bone cement (in case of cemented prosthesis) should be checked after the exclusion of other reasons like infection. If symptoms cannot be controlled by conservative measures, revision should be decided and carried out with hypoallergic prosthesis.