Hypersensitivity to benzoyl peroxide in a cemented total knee arthroplasty: cement allergy

Conversion of Unicompartmental Knee Arthroplasty to Total Knee Arthroplasty for Cement Allergy

Despite the success of unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA), complications leading to loosening and eventual failure can arise. While infection, instability, and aseptic loosening are some of most common causes of UKA and TKA failure, one of the less common reasons is delayed hypersensitivity reactions. While most allergic reactions are hypersensitivity reactions to metal, hypersensitivity reactions to other materials used in the procedure, such as polymethylmethacrylate bone cement, have begun to gain more attention in recent years. In this case report, we explore the unique instance of a patient who required a revision of a cemented UKA to TKA due to severe pain likely caused by a confirmed polymethylmethacrylate allergy.

The safety and efficiency of benzoyl peroxide for reducing Cutibacterium acnes in the shoulder: An updated systematic review and meta-analysis

Background

Cutibacterium acnes (C. acnes), a common pathogen, contributes significantly to infections in shoulder surgery. Prevention of shoulder infection is crucial to improve postoperative functional recovery and reduce costs. This study aimed to perform a systematic review and meta-analysis to assess the safety and efficacy of 5% benzoyl peroxide (BPO) application in the shoulder to decrease C. acnes.

Methods

Three electronic databases were searched as follows: PubMed, Embase, and the Cochrane Library databases. Data extraction for this study was performed by two independent reviewers, and only level I and level II studies were included. The outcome data sources of individual studies were pooled. The fixed-effect model was used to determine the meta-analysis.

Results

There were five level I studies and five level II studies. The results showed that the 5% BPO group had a lower risk of C. acnes positivity [OR, 0.21 (0.15, 0.30), I2 = 24, p < 0.00001]. The pooled analysis results showed that there was no significant difference in the ability of 5% BPO and 5% BPO + clindamycin to reduce C. acnes. However, the lower rate of adverse events was significantly in favour of the non-BPO group compared with the 5% BPO group.

Conclusion

BPO can decrease C. acnes in the shoulder to prevent infection. However, the combination of BPO and clindamycin does not enhance this effect further.

Level of evidence

II, Systematic review and meta-analysis.

Clinical Results of Revision TKA in Patients With Presumed Metal and Cement Allergy

BACKGROUND

Metal and cement allergy affects a small subset of patients, causing severe pain and often systemic reaction after total knee arthroplasty (TKA). Revision with ceramic-surfaced femoral components has been reported to resolve these symptoms of metal allergy, but no solution currently is available for patients with allergies to metal and bone cement.

METHODS

Five patients (5 knees) with documented metal allergy were revised with custom porous-coated ceramic femoral components (Magnesia-stabilized Zirconia) from January 2007 to January 2013. An additional 23 patients (23 knees) met inclusion criteria from 2007 to 2015, but because the ceramic implant was unavailable, they underwent different treatment based on their underlying allergy to metal, cement, or both. Inclusion criteria included the history of clinically documented severe metal allergy, severe pain, swelling, and effusion >1 year after TKA, negative workup for infection, loosening, and ligament imbalance. Knee Society scores were compared for each cohort.

RESULTS

Mean Knee Society scores for all 5 patients revised with custom cementless ceramic femoral components improved significantly for objective score (preoperative, 39 ± 5; most recent visit, 90 ± 2) and function score (preoperative, 33 ± 8; most recent visit 93 ± 4) (P < .0001). The 12 knees revised with off-the-shelf cemented ceramic-coated femoral components had similar results. The 7 unrevised knees (including 4 knees with allergy to metal and bone cement) and the 4 knees revised with standard CoCr femoral components did not improve and worsened over time.

CONCLUSION

Symptoms resolved in the 5 patients revised with custom ceramic implants and in the 12 patients revised with ceramic-coated components, but did not improve in the patients unrevised or revised with CoCr femoral components. Symptoms presumed to be associated with metal or cement allergy improve with the use of ceramic femoral surfaces, but patients who are allergic both to metals and bone cement would be candidates only for porous-coated ceramic implants fixed without bone cement.

Bone Cement Hypersensitivity in Patients With a Painful Total Knee Arthroplasty: A Case Series of Revision Using Custom Cementless Implants

Little is known about patients with bone cement hypersenstivity after total knee arthroplasty (TKA). We present 7 patients implanted with 8 TKAs with clinical failure and a cement hypersensitivity diagnosis. All demonstrated hypersensitivity to bone cement via skin patch and/or lymphocyte transformation testing. All 7 patients also showed hypersensitivity to metal, most commonly nickel. Patients underwent custom cementless TKA revision. Prerevision and postrevision outcome measures, radiographs, intraoperative findings, and postrevision complications are reported. Functional scores improved after revision except Veterans RAND-12 mental component scores, which declined. Four patients continue to exhibit symptoms postoperatively, while one patient has had 3 additional surgical procedures. Patients presenting with bone cement hypersensitivity after TKA are particularly challenging. Evidence-based guidelines are lacking, and revision surgery may not relieve the presenting symptoms.

Patch Test Results and Outcome in Patients with Complications from Total Knee Arthroplasty: A Consecutive Case Series

The role of hypersensitivity in implant-related complications remains controversial. The objectives of our study were to (1) establish the prevalence of hypersensitivity to components of knee prostheses in patients referred to our contact dermatitis clinic, (2) determine if patients with post-surgery dermatitis have become sensitized, and (3) describe the outcome of patients with and without hypersensitivity. We reviewed the charts of patients referred from 2007 to 2018 and extracted demographic information, date, type, and site of implant, clinical presentation, and results of patch testing (PT) or lymphocyte transformation tests (LTT). We called most patients to gather data such as clinical outcome, nature, and timing of additional surgery. Statistical analysis included computation of conventional descriptive statistics. Because of the type of study design, only some categorical variables were tested for possible associations by analytical tools (cross-tabulation). Thirty-nine patients, 23 men (59.0%), and 16 women (41.0%), were included. Their mean age in years was 63.3 (95% confidence interval [CI]: 60.9-65.7) ranging from 39.0 to 79.0, (standard deviation) = 9.69, without statistically significant differences between males and females. Five patients had positive PT possibly relevant to their implant. Four patients had revision surgery and two improved. Of nine patients with dermatitis, one with relevant PT did not improve after revision, and the dermatitis was unrelated to TKA in eight. Of the 26 patients without dermatitis or relevant PT results, 9 had revisions because of incapacitating symptoms, and 5 improved. Hypersensitivity to implant components is a potential factor in the etiology of TKA complications. Patients with confirmed hypersensitivity may benefit from revision. Our study, however, did not detect statistically significant differences in outcome of revision surgery between patients with positive versus negative PT or LTT. In spite of this, we consider that patients with a history suggestive of metal, acrylate or aminoglycoside allergy should be tested preoperatively to avoid hypersensitivity-related postoperative complications. In the absence of hypersensitivity, some patients with incapacitating symptoms may also improve following revision.

The role of antibiotic-loaded bone cement in complicated knee arthroplasty: relevance of gentamicin allergy and benefit from revision surgery - a case control follow-up study and algorithmic approach

BACKGROUND

Antibiotic-loaded (particularly gentamicin) bone cement (BC) is widely used in total joint arthroplasty (TJA) to prevent periprosthetic infections (PPIs), but may itself cause implant failure. In light of a complete lack in literature, the objective was to assess the clinical relevance of gentamicin allergy for failure of cemented total knee arthroplasties in 25 out of 250 patients with positive patch test reactions to gentamicin and otherwise unexplained symptoms by evaluating benefits from revision with change to gentamicin-free cement.

METHODS

Fifteen of these 25 patients and their treating orthopaedic surgeons agreed to a re-assessment. They were surveyed regarding interim course of therapy and symptoms, including re-assessment of the Knee Injury and Osteoarthritis Outcome Score (KOOS), and underwent follow-up clinical and radiographic investigations. The initial use of gentamicin-loaded BC was reaffirmed by review of the primary implantation operative reports and respective implant passports. Primary and follow-up KOOS scores were analyzed regarding benefits from revision surgery by comparing nine patients with revision to six without revision.

RESULTS

Mean follow-up time was 38 months. The entirety of patients experienced an improvement of self-reported symptoms, with revision surgery (i.e., switching to gentamicin-free BC or uncemented total knee arthroplasty) yielding significantly greater improvement (p = 0.031): the nine revised patients reported a significant symptom relief (p = 0.028), contrary to the six unrevised patients (p = 0.14). Interestingly, the decision to proceed with revision surgery was significantly correlated with higher symptom severity (p = 0.05).

CONCLUSION

In symptomatic total knee arthroplasty with gentamicin allergy, uncemented revision arthroplasty or change to gentamicin-free BC provides significant symptom relief.

Increased risk of eczema after joint replacement: A population-based retrospective cohort study

There are very few reports of eczema and other prosthetic-related allergic skin complications following arthroplasty. We aimed to assess the risk of eczema after joint replacement.We performed a retrospective population-based cohort study in 2024 joint replacement patients using the Longitudinal Health Insurance Database. For comparison, 8096 controls were selected, with 4 control subjects for each joint replacement patient matched for age, sex, and index year, to assess eczema risk. We examined 14-year cumulative eczema incidence associated with age, sex, immunity, disease history, and joint replacement location.Eczema rates in the joint replacement patients were 38% higher than in the control group (57.90 vs 41.84 per 1000 person-years, respectively). Compared with the control group, joint replacement patients showed a 1.35-fold increased risk of eczema according to the multivariable Cox model (95% Confidence interval [CI] = 1.23-1.49). Knee replacement patients had higher eczema risk compared with the control group (Hazard ratio [HR] = 1.45, 95% CI = 1.33-1.70). Stratified by study period, the joint replacement cohort had a higher eczema risk after the 3-month follow-up.Our study revealed that joint arthroplasty increased risk of eczema in this 14-year follow-up study, and this was not related to personal atopic history or gender.

Metal hypersensitivity in patients with orthopaedic implant complications-A retrospective clinical study

BACKGROUND

Hypersensitivity to metals as a cause of implant-related complications has been a subject of controversy. Projections indicate an increase in the frequency of joint replacements of between 300% and 600% by the year 2030; therefore, this issue is of considerable interest.

OBJECTIVE

To evaluate sensitization to implant materials in patients with implant-related complications, to identify allergens, and to clarify whether hypersensitivity is a relevant cause.

METHODS

Patients with implant-related complications or a positive history of contact allergy and planned total joint replacements referred for allergological investigation between 2004 and 2017 were retrospectively analysed.

RESULTS

In total, 311 patients were included. A positive patch test reaction to a metal was seen in 64.4% of preoperative patients and in 54.6% of patients with implant-related complications. Common alloy metals such as cobalt, chromium and titanium gave positive reactions in up to 2.9% of patients with implant-related complications. None of the patients with skin changes had a positive patch test reaction to an implant metal.

CONCLUSION

Other factors, such as the type of replaced joint and mechanical stress, seem to be more relevant for implant-related complications. Sensitization to metals or other materials seems to rarely play a role, and is overestimated.

Cranioplasty

Cranioplasty following craniectomy for trauma is a common, safe neurosurgical procedure that restores the natural cosmesis and protective barrier of the skull and may be instrumental in normalizing cerebrospinal fluid dynamics after decompressive surgery. Understanding the factors influencing patient selection and timing of cranioplasty, the available materials and methods of skull reconstruction, and the technical nuances is critical for a successful outcome. Neurosurgeons must be prepared to manage the complications specific to this operation. This article reviews the indications, preoperative assessment and timing, most commonly used materials, operative technique, postoperative care, and complication management for cranioplasty.

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.

Allergies in orthopaedic and trauma surgery

Hypersensitivity reactions to implants in orthopaedic and trauma surgery are a rare but devastating complication. They are considered as a delayed-type of hypersensitivity reaction (type IV), characterized by an antigen activation of sensitized T-lymphocytes releasing various cytokines and may result in osteoclast activation and bone resorption. Potential haptens are originated from metal alloys or bone-cement. A meta-analysis has confirmed a higher probability of developing a metal hypersensitivity postoperatively and noted a greater risk of failed replacements compared to stable implants. Hypersensitivity to implants may present with a variety of symptoms such as pain, joint effusion, delayed wound/bone healing, persistent secretion, allergic dermatitis (localized or systemic), clicking noises, loss of joint function, instability and failure of the implant. Various diagnostic options have been offered, including patch testing, metal alloy patch testing, histology, lymphocyte transformation test (LTT), memory lymphocyte immunostimulation assay (MELISA), leukocyte migration inhibition test (LIF) and lymphocyte activation test (LAT). No significant differences between in vivo and in vitro methods have been found. Due to unconvincing evidence for screening methods, predictive tests are not recommended for routine performance. Infectious aetiology always needs to be excluded. As there is a lack of evidence on large-scale studies with regards to the optimal treatment option, management currently relies on individual case-by-case decisions. Several options for patients with (suspected) metal-related hypersensitivity exist and may include materials based on ceramic, titanium or oxinium or modified surfaces. Promising results have been reported, but long-term experience is lacking. More large-scaled studies are needed in this context. In patients with bone-cement hypersensitivity, the component suspected for hypersensitivity should be avoided. The development of (predictive) biomarkers is considered as a major contribution for the future.

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.

Biomaterial hypersensitivity: is it real? Supportive evidence and approach considerations for metal allergic patients following total knee arthroplasty

The prospect of biomaterial hypersensitivity developing in response to joint implant materials was first presented more than 30 years ago. Many studies have established probable causation between first-generation metal-on-metal hip implants and hypersensitivity reactions. In a limited patient population, implant failure may ultimately be related to metal hypersensitivity. The examination of hypersensitivity reactions in current-generation metal-on-metal knee implants is comparatively limited. The purpose of this study is to summarize all available literature regarding biomaterial hypersensitivity after total knee arthroplasty, elucidate overall trends about this topic in the current literature, and provide a foundation for clinical approach considerations when biomaterial hypersensitivity is suspected.