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Pahlavan S, Hegde V, Bracey DN, Jennings JM, Dennis DA. Bone Cement Hypersensitivity in Patients With a Painful Total Knee Arthroplasty: A Case Series of Revision Using Custom Cementless Implants. Arthroplast Today 2021; 11:20-24. [PMID: 34409143 PMCID: PMC8361018 DOI: 10.1016/j.artd.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Sheila Pahlavan
- Colorado Joint Replacement, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Vishal Hegde
- Colorado Joint Replacement, Denver, CO, USA.,Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Daniel N Bracey
- Colorado Joint Replacement, Denver, CO, USA.,Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Jason M Jennings
- Colorado Joint Replacement, Denver, CO, USA.,Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
| | - Douglas A Dennis
- Colorado Joint Replacement, Denver, CO, USA.,Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA.,Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO, USA.,Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
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Armonies S, Zajonz D, Treudler R, Roth A, Ghanem M. Long-term outcome after implantation of a nickel-containing cemented hip stem on the right in a patient with type IV sensitization to nickel sulphate. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2019; 8:Doc18. [PMID: 32047716 PMCID: PMC6997891 DOI: 10.3205/iprs000144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Type IV allergies to nickel sulfate, potassium dichromate and/or cobalt chloride are supposed to be associated with aseptic loosening, pain or infections in patients with hip arthroplasty. However, there is debate on any causal relation between type IV sensitization to metals and any of these complications. We report on a patient with suspicion of pre-existing type IV sensitization to nickel sulfate and potassium dichromate who did not show any complications after hip arthroplasty.
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Affiliation(s)
- Sarah Armonies
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Germany
| | - Dirk Zajonz
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Germany
| | - Regina Treudler
- Department of Dermatology, Venerology and Allergology, University Hospital Leipzig, Germany
| | - Andreas Roth
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Germany
| | - Mohamed Ghanem
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Germany
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Fröschen FS, Gravius N, Lau JF, Randau TM, Kaup E, Friedrich MJ, Gravius S. A case series of cementless revision total knee arthroplasty in patients with benzoyl peroxide allergy. INTERNATIONAL ORTHOPAEDICS 2018; 43:2323-2331. [PMID: 30539218 DOI: 10.1007/s00264-018-4273-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/03/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE The contact allergens nickel, cobalt, and chromium are often discussed as possible triggers of allergic reactions to orthopedic implants. Additionally, acrylates and polymerization additives in bone cement (e.g., benzoyl peroxide (BPO)) have been implicated as triggers of eczema, wound healing disorders, and aseptic implant loosening. We report about six patients with aseptic loosening after total knee arthroplasty (TKA), who underwent revision surgery after testing positive for BPO hypersensitivity. METHODS After clarification of possible other causes of implant failure, epicutaneous testing had been performed and the implants were replaced in a two-stage procedure with cementless, diaphyseal anchoring, hypoallergenic (TiNb-coated) revision endoprostheses. RESULTS Epicutaneous testing revealed a BPO allergy in all six patients and an additional nickel allergy in three of the six patients. There was no histopathological or microbiological evidence for a periprosthetic infection. The clinical follow-up showed a low level of pain with good function, a stable knee joint, and proper implant position. The Knee Society Score (KSS) with its subscales Knee Score and Functional Score improved post-operatively from 43 to 70 points and from 47.5 to 68.3 points, respectively. Two implant-specific complications occurred: femoral stress shielding two years post-operatively with no further need for action and aseptic loosening of the tibial stem with the need of revision three years post-operatively. CONCLUSIONS The regression of complaints after replacement with cementless and nickel-free revision implants suggests allergic implant intolerance. Implantation of a cementless, hypoallergenic endoprosthesis might, therefore, be a surgical treatment strategy in patients with evidence of allergies.
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Affiliation(s)
- Frank S Fröschen
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany.
| | - Nadine Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Jan-Frederic Lau
- Department of Pathology, University Hospital Bonn, Bonn, Germany
| | - Thomas Martin Randau
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Eva Kaup
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Max J Friedrich
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Sascha Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
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Furrer S, Scherer Hofmeier K, Grize L, Bircher AJ. Metal hypersensitivity in patients with orthopaedic implant complications-A retrospective clinical study. Contact Dermatitis 2018; 79:91-98. [PMID: 29888396 DOI: 10.1111/cod.13032] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/15/2018] [Accepted: 04/19/2018] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Stefan Furrer
- Department of Dermatology, Allergy Unit, University Hospital, Basel, Switzerland
| | | | - Leticia Grize
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Andreas J Bircher
- Department of Dermatology, Allergy Unit, University Hospital, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Abstract
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.
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Lieberman P, Fonacier L. Systemic contact dermatitis possibly related to metal implants. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:487. [PMID: 25017546 DOI: 10.1016/j.jaip.2014.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 02/17/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
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Diehl P, Haenle M, Bergschmidt P, Gollwitzer H, Schauwecker J, Bader R, Mittelmeier W. [Cementless total hip arthroplasty: a review]. ACTA ACUST UNITED AC 2012; 55:251-64. [PMID: 20958235 DOI: 10.1515/bmt.2010.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of total hip replacement (THR) is the restoration of a painless functioning hip joint with the main focus on the biomechanical properties. Advances in surgical techniques and biomaterial properties currently allow predictable surgical results in most patients. Despite the overwhelming success of this surgical procedure, the debate continues surrounding the optimal choice of implants and fixation. Femoral and acetabular implants with varying geometries and fixation methods are currently available. Problems inherent with acrylic bone cement, however, have encouraged surgeons to use alternative surfaces to allow biologic fixation. Optimal primary and secondary fixation of cementless hip stems is a precondition for long-term stability. Important criteria to achieve primary stability are good rotational and axial stability by press-fit fixation. The objective of the cementless secondary fixation is the biological integration of the implant by bony ingrowth. Nevertheless, current investigations show excellent results of cementless fixation even in older patients with reduced osseous quality. The main advantages of cementless fixation include biological integration, reduced duration of surgery, no tissue damage by cement polymerization and reduction of intraoperative embolisms. In comparison to cemented THR both, cementless sockets and stems provide good long-term results.
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Affiliation(s)
- Peter Diehl
- Orthopädische Klinik und Poliklinik, Universität Rostock, Rostock, Deutschland.
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Bircher A, Friederich NF, Seelig W, Scherer K. Allergic complications from orthopaedic joint implants: the role of delayed hypersensitivity to benzoyl peroxide in bone cement. Contact Dermatitis 2011; 66:20-6. [DOI: 10.1111/j.1600-0536.2011.01996.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Reich J, Hovy L, Lindenmaier HL, Zeller R, Schwiesau J, Thomas P, Grupp TM. [Preclinical evaluation of coated knee implants for allergic patients]. DER ORTHOPADE 2010; 39:495-502. [PMID: 20091294 DOI: 10.1007/s00132-009-1581-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND 10-15% of the population show allergic reactions against skin contact to metals as nickel, cobalt or chromium and have thus a risk of not tolerating implants containing those materials. The relationship between periimplantary hypersensivity reaction and given cutaneous contact allergy is currently unknown. A new developed multilayer coating system is supposed to prevent long-term allergic reactions that may result from uncoated implants. METHODS Stability and function (concerning bonding durability, wear and ion release to the serum) of the multilayer coating system has been examined in a test series. RESULTS The specific architecture of the multilayer coating system evidences a very good bonding durability. The results of the test in the simulator show a reduction of wear of approximately 60% compared to the uncoated implants. Ion concentrations within the serum of the wear tests were by magnitudes lower than those measured in reference tests on uncoated components. CONCLUSION The results of the preclinical evaluation prove that the durability and function of the multilayer coating system are as intended.
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Affiliation(s)
- J Reich
- Forschung & Entwicklung, Aesculap AG, Am Aesculap-Platz, 78532, Tuttlingen, Deutschland.
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Eben R, Walk R, Summer B, Maier S, Thomsen M, Thomas P. Implantatallergieregister – ein erster Erfahrungsbericht. DER ORTHOPADE 2009; 38:557-62. [DOI: 10.1007/s00132-009-1414-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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[Orthopedic surgical implants and allergies. Joint statement by the Implant Allergy Working Group (AK 20) of the DGOOC (German Association of Orthopedics and Orthopedic Surgery), DKG (German Contact Dermatitis Research Group) and DGAKI (German Society for Allergology and Clinical Immunology)]. Hautarzt 2008; 59:220-9. [PMID: 18210000 DOI: 10.1007/s00105-007-1453-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Materials used in osteosynthesis or artificial joint replacement are usually well tolerated. Complaints after such operations are mostly related to infection or mechanical problems but may also be caused by allergic reactions. The latter encompass skin changes, e.g., eczema, delayed wound/bone healing, recurrent effusion, pain, or implant loosening. In contrast to the high incidence of cutaneous metal contact allergy, allergies associated with implants are a rare condition. However, epidemiological data on the incidence of implant-related allergic reactions are still missing. Typical elicitors are nickel, chromium, cobalt, and constituents of bone cement (acrylates und additives such as gentamicin or benzoyl peroxide). After exclusion of the most common differential diagnoses, allergy diagnostic procedures are primarily based on patch tests including a metal and bone cement component series. Additional analysis of periimplant tissue is recommended. However, further studies are necessary to show the significance of the histologic findings and the role of the lymphocyte transformation test (LTT). Which combinations of factors will induce allergic sensitization to implants or trigger periimplant allergic reactions in the case of preexisting cutaneous metal allergy is still unknown. Titanium-based osteosynthesis materials are recommended for metal allergic patients. In elective hip replacements, a ceramic/polyethylene (PE) articulation should be used, and in knee replacements "alternative materials". If a regular, potentially applicable CoCr/PE articulation is preferred, the patient must be well informed and must give his/her written consent.
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Thomas P, Schuh A, Eben R, Thomsen M. Allergie auf Knochenzementbestandteile. DER ORTHOPADE 2008; 37:117-20. [PMID: 18227996 DOI: 10.1007/s00132-008-1195-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- P Thomas
- Klinik und Poliklinik für Dermatologie und Allergologie , Ludwig-Maximilians-Universität, Frauenlobstrasse 9-11, 80337, München, Deutschland.
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[Recurrent effusion and granulomatous synovitis following total knee arthroplasty in association with latex allergy]. DER ORTHOPADE 2008; 37:111-6. [PMID: 18210090 DOI: 10.1007/s00132-007-1187-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
An increasing number of articles report about allergic reactions in association with total knee arthroplasty. While most studies focus on allergic reactions to metallic components, few reports exist about reactions to bone cement or its ingredients. Allergy to natural rubber latex is a major occupational problem in the health care sector and a problem even in other occupations in which protective gloves are used. The allergic reaction to latex ranges from a minor skin rash to anaphylactic shock. Preventing exposure to latex is the key to managing and preventing this allergy. We report about a patient who developed recurrent effusion and granulomatous synovitis following total knee arthroplasty in association with latex allergy.
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Kircher J, Bergschmidt P, Bader R, Kluess D, Besser-Mahuzir E, Leder A, Mittelmeier W. Die Bedeutung der Gleitpaarung beim jüngeren Endoprothesenpatienten. DER ORTHOPADE 2007; 36:337-46. [PMID: 17387448 DOI: 10.1007/s00132-007-1069-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The success and long-term survival rates of modern joint arthroplasty leads to a high patient satisfaction and, together with its technical improvements, has broadened the indications to an increasingly younger population. Limitations to the established systems are the long-term survival rates, which are mainly influenced by wear of the articulating parts and the resulting problems. Beside "classic" long-stemmed cemented shafts articulating with metal against polyethylene, short-stemmed or cup designs with a hard-hard self pairing are increasingly used in total hip arthroplasty. This paper reflects the current state of the art in joint arthroplasty for younger patients with the focus on wear couples and discusses future perspectives. Special interest is focused on the advantages and disadvantages of ceramic bearings, problems with allergies to implant components and the design of endoprostheses with regard to avoidance of impingement.
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Affiliation(s)
- J Kircher
- Orthopädische Klinik und Poliklinik, Universität Rostock, Doberaner Strasse 142, 18057 Rostock, Deutschland.
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