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Deroche E, Batailler C, Shatrov J, Gunst S, Servien E, Lustig S. No clinical difference at mid-term follow-up between TiN-coated versus uncoated cemented mobile-bearing total knee arthroplasty: a matched cohort study. SICOT J 2023; 9:5. [PMID: 36757220 PMCID: PMC9910165 DOI: 10.1051/sicotj/2023001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/05/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Nitride-based ceramic coating was introduced into surgical implants to improve hardness, reduce abrasion, and decrease the risk of metal-induced adverse reactions, especially for patients with suspected or identified metal hypersensitivity. The study aimed to evaluate the effectiveness and safety of a titanium nitride (TiN) coated prosthesis with a mobile bearing design. METHODS This was a retrospective matched-cohort study from a single center, comparing clinical outcomes between patients receiving either a TiN-coated versus an uncoated cobalt-chromium-molybdenum (CoCrMo) prostheses for primary total knee replacement. Seventeen patients received the TiN prosthesis between 2015 and 2019. These were matched 1:2 with patients receiving uncoated mobile-bearing knee prostheses with the same design manufacturer. RESULTS Fourteen patients in the TiN group had complete 5-year follow-up data and were compared with 34 patients from the CoCrMo group. The Knee Society Score was 170.6 ± 28.0 (Function subscore 83.7 ± 17.5 and Knee subscore 86.9 ± 13.8) in the TiN group and 180.7 ± 49.4 (Function subscore 87.5 ± 14.3 and Knee subscore 93.2 ± 9.6) in CoCrMo group, with no statistically significant difference (p = 0.19). One patient underwent a revision for instability requiring the removal of the implant in the TiN group and none in the CoCrMo group. The survival rates were 92.9% (CI95% 77.3-100.0) and 100.0% in the TiN group and CoCrMo group respectively (p = 1.0). DISCUSSION TiN-coated TKA with mobile bearing resulted in satisfactory clinical outcomes, and a low revision rate, and there was no complication related to the coated implant. The use of TiN-coated prostheses in case of confirmed or suspected metal allergy provides satisfactory short-term clinic outcomes.
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Affiliation(s)
- Etienne Deroche
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France,Corresponding author:
| | - Cécile Batailler
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France
| | - Jobe Shatrov
- Sydney Orthopaedic Research Institute (SORI) at Landmark Orthopaedics 500 Pacific Hwy St. Leonards NSW Australia
| | - Stanislas Gunst
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France
| | - Elvire Servien
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France,LIBM – EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University 69622 Lyon France
| | - Sébastien Lustig
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France,University of Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
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Thienpont E. Titanium niobium nitride knee implants are not inferior to chrome cobalt components for primary total knee arthroplasty at medium-term follow-up. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04754-1. [PMID: 36595031 DOI: 10.1007/s00402-022-04754-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Oxidized zirconium (Oxinium), titanium nitride (TiN) or titanium niobium nitride (TiNbN) coated implants became in recent years available for an increasing amount of total knee arthroplasty (TKA) systems. The hypothesis of this study was that the use of TiNbN-coated components would not lead to inferior results compared to conventional implants and that none of the metal hypersensitivity patients receiving TiNbN-coated implants would require revision for metal allergy. MATERIALS AND METHODS This retrospective study compared 53 Titanium Niobium Nitride coated TKA with 103 conventional chrome cobalt implants of the same design. Patients were evaluated at a minimal follow-up of 3 years. RESULTS No differences in clinical, radiological or patient-reported outcome measurements were observed between these groups. A survivorship of 96% without differences in revision rates was observed at medium-term follow-up of 6.5 years. DISCUSSION Metal allergy leading to contact or generalized dermatitis after TKA is very rare and usually linked to chrome or cobalt hypersensitivity. Nickel release from knee implants has not been shown to lead to cutaneous symptoms, but unexplained pain and swelling, peri-prosthetic osteolysis and component loosening remain potential issues not fully understood. The use of coated implants eliminates this factor from the diagnostic equation in case of postoperative dissatisfaction. CONCLUSION The use of titanium niobium nitride coated implants for primary knee osteoarthritis in self-reported metal hypersensitivity patients shows similar outcomes and survivorship rates as conventional chrome cobalt TKA, with no revisions for allergy at medium-term follow-up.
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Affiliation(s)
- Emmanuel Thienpont
- Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
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Kost Y, Shokrian N, Nazarian RS, Mattis DM, Amin B, McLellan BN, Kamara E. An Unexpected Postsurgical Phenomenon After Total Knee Arthroplasty: Nummular Eczema: A Case Report and Literature Review. JBJS Case Connect 2023; 13:01709767-202303000-00005. [PMID: 36821096 DOI: 10.2106/jbjs.cc.22.00345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 11/01/2022] [Indexed: 02/24/2023]
Abstract
CASES Two elderly women each presented with a unilateral, erythematous rash 1 year after total knee arthroplasty (TKA) for osteoarthritis. Both cases were diagnosed as postsurgical nummular eczema (NE) and treated successfully with topical corticosteroids. CONCLUSION We highlight a novel clinical presentation of postsurgical NE associated with TKA, previously reported only with breast reconstruction. Postsurgical NE may mimic periprosthetic infection or implant-related allergic contact dermatitis. Timely diagnosis and appropriate treatment in these cases prevented unnecessary testing and hospital admission for revision surgery. This case series highlights the varied presentation and wide differential diagnosis associated with postsurgical NE.
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Affiliation(s)
- Yana Kost
- Albert Einstein College of Medicine, Montefiore Medical Center, New York, New York
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Peacock CJH, Fu H, Asopa V, Clement ND, Kader D, Sochart DH. The effect of Nickel hypersensitivity on the outcome of total knee arthroplasty and the value of skin patch testing: a systematic review. ARTHROPLASTY 2022; 4:40. [PMID: 36050799 PMCID: PMC9438335 DOI: 10.1186/s42836-022-00144-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To assess the Nickel sensitizing potential of total knee arthroplasty (TKA), explore the relationship between hypersensitivity and clinical outcomes, and evaluate the utility of skin patch testing pre- and/or postoperatively.
Materials and methods
A literature search was performed through EMBASE, Medline and PubMed databases. Articles were screened independently by two investigators. The level of evidence of studies was assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the quality evaluated using the Methodological Index for Non-randomized Studies and Cochrane risk-of-bias tools.
Results
Twenty studies met the eligibility criteria, reporting on 1354 knee arthroplasties. Studies included patients undergoing primary or revision TKA, pre- and/or postoperatively, and used patch testing to identify Nickel hypersensitivity. Prevalence of Nickel hypersensitivity ranged from 0% to 87.5%. One study compared the prevalence of Nickel hypersensitivity in the same patient group before and after surgery and noted newly positive patch test reactions in three patients (4.2%). Three studies reported lower prevalence of Nickel hypersensitivity in postoperative patients compared to preoperative ones. Seven studies suggested that hypersensitivity might cause adverse clinical outcomes, but six did not support any relationship. Seven studies recommended preoperative patch testing in patients with history of metal allergy, and nine concluded that testing may be valuable postoperatively.
Conclusions
Patients undergoing TKA with no prior history of metal hypersensitivity do not seem to be at an increased risk of developing Nickel hypersensitivity, and there is conflicting evidence that patients with pre-existing hypersensitivity are more likely to experience adverse outcomes. Patch testing remains the most commonly used method for diagnosing hypersensitivity, and evidence suggests preoperative testing in patients with history of metal allergy to aid prosthesis selection, and postoperatively in patients with suspected hypersensitivity once common causes of implant failure have been excluded, since revision with hypoallergenic implants may alleviate symptoms.
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Battaglia AG, Ali-Zade C, Monti L, Al Khawashki H, Winkler H, Del Sel H, Mavrogenis AF, Benzakour T, Drago L, Romanò CL. Metal Hypersensitivity or Missed Periprosthetic Joint Infection? A Critical Review. Orthopedics 2022; 45:e73-e78. [PMID: 34978510 DOI: 10.3928/01477447-20211227-04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The World Association Against Infection in Orthopedics And Trauma (W.A.I.O.T.) Study Group on Bone And Joint Infection Definitions Metal hypersensitivity (MHS) has been investigated by several authors as a possible reason for painful total joint arthroplasty, with controversial results. Periprosthetic joint infection (PJI) is another possible source of unexplained pain and implant failure that may be difficult to diagnose if not properly investigated. We performed this critical review to assess whether the current literature on MHS includes an adequate diagnostic workup to discern metal allergy from PJI. The results of this review highlight the importance of assessing patients for PJI before making a diagnosis of MHS and emphasize that the methods currently used to exclude PJI are substantially inadequate. Therefore, well-designed clinical trials with adequate diagnostic protocols and definitions of PJI that can differentiate MHS from low-grade PJI are needed. [Orthopedics. 2022;45(2):e73-e78.].
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No Clinical or Radiographic Differences Between Cemented Cobalt-Chromium and Titanium-Niobium Nitride Mobile-Bearing Unicompartmental Knee Arthroplasty. Indian J Orthop 2021; 55:1195-1201. [PMID: 34824720 PMCID: PMC8586226 DOI: 10.1007/s43465-021-00486-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/10/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to compare the clinical and radiographic outcomes of patients with positive patch tests undergoing a medial mobile-bearing titanium-niobium nitride (TiNbN) unicompartmental knee arthroplasty (UKA) to patients undergoing standard UKA (cobalt-chromium [CoCr] implants). METHODS Two successive groups of patients, amounting to a total of 246 individuals, who received Oxford (Zimmer-Biomet, Warsaw, Indiana, USA) UKA were included. The first group was composed of a series of 203 consecutive standard CoCr UKAs (Standard Group), while the second group comprised 43 consecutive hypoallergenic TiNbN UKAs (HA group). The patients of the second group had a positive epicutaneous patch test result for metals. Each patient was evaluated using the Oxford Knee Score (OKS) and Knee Society Score (KSS) a day prior to the surgery (T 0) and at two consecutive follow-ups, namely T 1 (minimum follow-up of 12 months) and T 2 (minimum follow-up of 34 months). Radiographic measurements were performed at the final follow-up (T 2). RESULTS No statistical differences were noted between the two groups regarding demographic data (p > 0.05). No clinical or radiographic differences were found between the HA and standard groups at any follow-up (p > 0.05). A statistically significant improvement was found at any follow-up for both OKS and KSS (p < 0.05). CONCLUSIONS No clinical or radiographic differences between the hypoallergenic and standard cobalt-chromium groups at any follow-up were found, with a clinically significant improvement being experienced by both groups during the entire follow-up. LEVEL OF EVIDENCE Level II-comparative prospective study. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00486-3.
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Sasseville D, Alfalah K, Savin E. Patch Test Results and Outcome in Patients with Complications from Total Knee Arthroplasty: A Consecutive Case Series. J Knee Surg 2021; 34:233-241. [PMID: 31434145 DOI: 10.1055/s-0039-1694984] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Denis Sasseville
- Division of Dermatology, McGill University Health Centre, Montréal, Canada
| | - Khuzama Alfalah
- Division of Dermatology, McGill University Health Centre, Montréal, Canada
| | - Evgeny Savin
- Division of Dermatology, McGill University Health Centre, Montréal, Canada
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Mencia MM, Cawich SO. Allergic Dermatitis Following Bilateral Oxidized Zirconium Total Knee Replacements. J Orthop Case Rep 2021; 11:67-70. [PMID: 34141674 PMCID: PMC8180328 DOI: 10.13107/jocr.2021.v11.i02.2030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Total knee replacement (TKR) utilization is expected to increase by 673% in 2030, with patients between the ages of 45 to and 64 years representing the fastest-growingfastest growing age group requiring joint replacement. This group not only demands a higher- performinghigher performing, durable prosthesis but are is also the most likely to be dissatisfied if their expectations are not met. Hypo-allergenic implants have been developed by some implant manufacturers to fill this need, so the occurrence of allergic skin reactions after surgery is unanticipated and can have unwanted consequences if not recognized and managed appropriately. Case Report: We present the case of a 55-year-old woman who underwent bilateral staged TKR using oxidized zirconium implants and subsequently developed eczematous skin reactions. In both instances, she presented with a peri-incisional erythematous blistering skin reaction that was successfully treated with topical corticosteroids. Investigations revealed no evidence of infection or allergic-typeallergic type reactions to the metals contained in the knee replacements. Conclusion: Allergic skin reactions following TKR are very rare, and are not necessarily due to a metal hypersensitivity. Infection must be excluded in all cases and a trial of topical corticosteroids is useful before prior to more aggressive treatment, with the removal of the implant reserved as a last resort. To the best of our knowledge, this is the first case in the literature that reports the occurrence of allergic skin reactions following oxidized zirconium TKRs, and highlights the fact that allergic skin reactions can occur when using hypo-allergenic implants. Surgeons should be aware of this possibility and counsel their patients appropriately during the informed consent process.
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Affiliation(s)
- Marlon M Mencia
- Department of Orthopaedics, Westshore Medical Private Hospital, Cocorite, Trinidad, West Indies
| | - Shamir O Cawich
- Department of Orthopaedics, Westshore Medical Private Hospital, Cocorite, Trinidad, West Indies
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Thomas P, Summer B, Thyssen JP. Hypersensitivity Reactions to Orthopedic Implants. Contact Dermatitis 2021. [DOI: 10.1007/978-3-030-36335-2_80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Nazeer M, Ravindran R, Katragadda BC, Muhammed EN, Rema DTJ, Muhammed MN. SKINTED: A Rare Complication After Total Knee Arthroplasty. Arthroplast Today 2020; 6:1028-1032. [PMID: 33385046 PMCID: PMC7772457 DOI: 10.1016/j.artd.2020.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/05/2020] [Accepted: 10/17/2020] [Indexed: 11/26/2022] Open
Abstract
Background Surgery of the knee, injury to the infrapatellar branch of the saphenous nerve, traumatic eczematous dermatitis is a neuropathic dermatitis specific to total knee arthroplasty (TKA), occurring around the healed surgical scar area. Very few case reports exist in orthopaedic literature regarding this rare skin complication after TKA. We report a series of cases and estimated the incidence of this condition in our institute. Methods During the 1-year period from January 2018 to December 2018, patients who have undergone TKA and later presented with skin lesions adjacent to the operated site were identified. Detailed history was taken, and full clinical examination was performed for all the reported cases. Results A total of 9 lesions in 8 patients were identified out of a total of 203 consecutive TKAs operated during the study period, with an estimated incidence of 4.4%. The mean age was 64 years (range, 58-78 years). The mean time from surgery to diagnosis was 4 months (range, 3-6 months). Conclusions This group of dermatitis caused due to surgical transection of the infrapatellar branch of the saphenous nerve during TKA is a rare cutaneous complication, with an estimated incidence of 4.4% from this study. Lesions typically appear lateral to the operative scar within an area of hypoesthesia. Lesions in all patients improved after topical steroid therapy with no recurrences at further follow-up. Arthroplasty surgeons should have awareness of this benign complication, thereby avoiding unwarranted additional workup and alleviating unnecessary psychological stress to the patient.
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Affiliation(s)
- Muhammed Nazeer
- Division of Arthroplasty, Department of Orthopedics, Kerala Institute of Medical Sciences, Anayara, Thiruvananthapuram, Kerala, India
| | - Rohith Ravindran
- Division of Arthroplasty, Department of Orthopedics, Kerala Institute of Medical Sciences, Anayara, Thiruvananthapuram, Kerala, India
| | - Bharat C Katragadda
- Division of Arthroplasty, Department of Orthopedics, Kerala Institute of Medical Sciences, Anayara, Thiruvananthapuram, Kerala, India
| | - Ehsan N Muhammed
- Department of Orthopedics, Kasturba Medical College, Mangalore, Karnataka, India
| | - Devi T J Rema
- Division of Dermatology and Cosmetology, Kerala Institute of Medical Sciences, Anayara, Thiruvananthapuram, Kerala, India
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Thomas P, Summer B, Thyssen JP. Orthopedic Implants. Contact Dermatitis 2020. [DOI: 10.1007/978-3-319-72451-5_80-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Thomas P, Summer B, Thyssen JP. Hypersensitivity Reactions to Orthopedic Implants. Contact Dermatitis 2020. [DOI: 10.1007/978-3-319-72451-5_80-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Two-Stage Revision Total Knee Arthroplasty for Suspected Periprosthetic Joint Infection and Metal and Bone Cement Hypersensitivity. JOURNAL OF POPULATION THERAPEUTICS AND CLINICAL PHARMACOLOGY 2019; 26:e40-e44. [PMID: 31904204 DOI: 10.15586/jptcp.v26i3.647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 10/29/2019] [Indexed: 11/18/2022]
Abstract
Hypersensitivity to implant components and periprosthetic joint infection should be detected before all revision arthroplasty, as misdiagnosis can lead to replacement loosening and the need for further revision procedures. We describe the case of a 69-year-old woman presenting a history of a painful cemented total knee replacement. Postoperative investigations showed loosening of X-ray components, suspected periprosthetic joint infection, and patch test hypersensitivity to nickel sulfate and methyl methacrylate. Two months later, a more specific patch test indicated non-allergy to the solid scratch of one bone cement. The patient underwent a two-stage revision with prosthesis removal and the temporary application of a specific cement spacer followed by the successful reimplantation of a cemented revision prosthesis. All candidates for the revision arthroplasty procedure must be investigated for hypersensitivity to metal and bone cement in order to avoid complications related to prosthesis intolerance and the need for further revision surgery; in the presence of hypersensitivity to bone cement and periprosthetic joint infection with a two-stage revision indication, the patient must be submitted to further patch tests with scratches of solid bone cement.
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van Veen SC, Huizinga MR, van Raaij JJAM. Popliteal Skin Lesion due to Wear Disease in Total Knee Arthroplasty: A Case Report. JBJS Case Connect 2019; 9:e0484. [PMID: 31688058 DOI: 10.2106/jbjs.cc.18.00484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE An 87-year-old woman presented with a popliteal skin lesion due to polyethylene wear 13 years following a left total knee arthroplasty. Excisional biopsy through a posterior approach was performed. Histology showed inflammation with granulomas and birefringent foreign body particles in the skin. Cultures remained negative, and revision knee arthroplasty was performed. CONCLUSIONS A popliteal skin lesion due to polyethylene wear disease in total knee arthroplasty has not previously been described. Patients with an atypical inflammation of the skin with an underlying joint implant should be referred to an orthopaedic surgeon, and dermal biopsies should be checked for birefringent material. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Steven C van Veen
- Orthopedic Surgery, Martini Hospital Groningen, Groningen, the Netherlands
| | - Maarten R Huizinga
- Orthopedic Surgery, Martini Hospital Groningen, Groningen, the Netherlands
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Abstract
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.
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Affiliation(s)
- Po-Yuan Wu
- Department of Dermatology, China Medical University Hospital
- School of Medicine, China Medical University
| | | | - Chun-Hao Tsai
- School of Medicine, China Medical University
- Department of Orthopedics, China Medical University Hospital
- Department of Sports Medicine/School of Medicine, China Medical University, Taichung, Taiwan
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Saccomanno MF, Sircana G, Masci G, Cazzato G, Florio M, Capasso L, Passiatore M, Autore G, Maccauro G, Pola E. Allergy in total knee replacement surgery: Is it a real problem? World J Orthop 2019; 10:63-70. [PMID: 30788223 PMCID: PMC6379738 DOI: 10.5312/wjo.v10.i2.63] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/26/2018] [Accepted: 01/06/2019] [Indexed: 02/06/2023] Open
Abstract
Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.
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Affiliation(s)
- Maristella F Saccomanno
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giuseppe Sircana
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giulia Masci
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Gianpiero Cazzato
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Michela Florio
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Luigi Capasso
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Marco Passiatore
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giovanni Autore
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giulio Maccauro
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Enrico Pola
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
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Phedy P, Djaja YP, Boedijono DR, Wahyudi M, Silitonga J, Solichin I. Hypersensitivity to orthopaedic implant manifested as erythroderma: Timing of implant removal. Int J Surg Case Rep 2018; 49:110-114. [PMID: 30005360 PMCID: PMC6037004 DOI: 10.1016/j.ijscr.2018.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 06/06/2018] [Accepted: 06/16/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Incidence of hypersensitivity to orthopaedic implant, once estimated in less than 1% of population, recently has increased to 10%. Controversies about the timing of implant removal remain, especially due to the fact that implant hypersensitivity may be a contributing factor to implant failure. We present a case report and literature reviews to establish the decision making for the timing of implant removal in the presence of implant hypersensitivity. PRESENTATION OF CASE Female, 42 years old with nonunion of mid-shaft tibia and fibula which was treated with ORIF with conventional SAE16 stainless steel plate and bone graft. A week after, she developed a generalized rash, which is later diagnosed as erythroderma, that relapsed despite adequate systemic corticosteroid. Poor healing of surgical site wound were marked. After the implant removal, the cutaneous condition improved and no relapse were found. DISCUSSION Management of hypersensitivity to implants involved corticosteroid administration, removal or replacement of implants, or implants coating with polytetrafluoroethylene. Currently there are no specific guidelines regulating the management of implant allergy based on the timing of the onset, especially in fracture cases. The decision-making would be straightforward if union was already achieved. Otherwise, controversies would still occur. In this paper, we proposed an algorithm regarding the steps in managing metal allergy due to implant in fracture cases. CONCLUSION Despite the concerns regarding implant survival in hypersensitivity cases, the decision whether the implant should be removed or replaced should be based on the time and condition of the fracture healing process.
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Affiliation(s)
- Phedy Phedy
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Yoshi P Djaja
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Dimas R Boedijono
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Muhammad Wahyudi
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Jamot Silitonga
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Iman Solichin
- Rumah Sakit Orthopaedi Purwokerto, Purwokerto, Indonesia.
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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: 22] [Impact Index Per Article: 3.7] [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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Akil S, Newman JM, Shah NV, Ahmed N, Deshmukh AJ, Maheshwari AV. Metal hypersensitivity in total hip and knee arthroplasty: Current concepts. J Clin Orthop Trauma 2018; 9:3-6. [PMID: 29628676 PMCID: PMC5884053 DOI: 10.1016/j.jcot.2017.10.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 01/23/2023] Open
Abstract
Metal hypersensitivity (MHS) is a rare complication of total joint arthroplasty that has been linked to prosthetic device failure when other potential causes have been ruled out. The purpose of this review was to conduct an analysis of existing literature in order to get a better understanding of the pathophysiology, presentation, diagnosis, and management of MHS. It has been described as a type IV hypersensitivity reaction to the metals comprising prosthetic implants, often nickel and cobalt-chromium. Patients suffering from this condition have reported periprosthetic joint pain and swelling as well as cutaneous, eczematous dermatitis. There is no standard for diagnosis MHS, but tests such as patch testing and lymphocyte transformation testing have demonstrated utility, among others. Treatment options that have demonstrated success include administration of steroids and revision surgery, in which the existing metal implant is replaced with one of less allergenic materials. Moreover, the definitive resolution of symptoms has most commonly required revision surgery with the use of different implants. However, more studies are needed in order to understand the complexity of this subject.
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Affiliation(s)
- Samuel Akil
- Department of Orthopaedic Surgery, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY, USA
| | - Jared M. Newman
- Department of Orthopaedic Surgery, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY, USA
| | - Neil V. Shah
- Department of Orthopaedic Surgery, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY, USA
| | - Natasha Ahmed
- Saba University School of Medicine, Saba, Caribbean Netherlands, Netherlands
| | - Ajit J. Deshmukh
- Department of Orthopaedic Surgery, NYU Langone Medical Center, VA New York Harbor Healthcare System, New York, NY, USA
| | - Aditya V. Maheshwari
- Department of Orthopaedic Surgery, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY, USA,Correspondence to: Adult Reconstruction and Musculoskeletal Oncology Divisions SUNY Downstate Medical Center 450 Clarkson Ave., Box 30 Brooklyn, New York 11203, USA.
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Teo WZW, Schalock PC. Metal Hypersensitivity Reactions to Orthopedic Implants. Dermatol Ther (Heidelb) 2017; 7:53-64. [PMID: 27995484 PMCID: PMC5336431 DOI: 10.1007/s13555-016-0162-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Indexed: 01/08/2023] Open
Abstract
Total hip and knee replacement surgery using metal alloy devices is common. Type IV allergic reactions to these implants occur, though infrequently. While uncommon, peri-implant metal allergic reactions may cause significant morbidity for the affected individual-including aseptic loosening, pseudotumor formation and frank device failure. It is challenging to predict who will have these reactions, even in those with established pre-implant metal allergy. At this time, the scientific literature clearly supports few conclusions. Despite this, we believe several conclusions can be made: routine pre-implant testing in asymptomatic individuals is not indicated; listen to patient's concerns about metal allergy if the concern arises; patch testing is probably the best pre- and post-implant screening test; post-implantation testing is controversial and even positive LTT or patch test does not definitively diagnose morbidity from a metal allergy; and complete recovery following revision placement of an immunologically inert device is diagnostic. More research is needed to scientifically approach this issue.
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Affiliation(s)
- Wendy Z W Teo
- Department of Surgery (Dermatology), Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Peter C Schalock
- Department of Surgery (Dermatology), Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
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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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Stathopoulos IP, Andrianopoulos N, Paschaloglou D, Tsarouchas I. Revision total knee arthroplasty due to bone cement and metal hypersensitivity. Arch Orthop Trauma Surg 2017; 137:267-271. [PMID: 28070650 DOI: 10.1007/s00402-016-2614-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Ioannis P Stathopoulos
- Orthopaedic Department, Athens Medical Center, 56, Kifisias ave and Delfon, 15125, Amaroussio, Athens, Greece.
| | - Nicolaos Andrianopoulos
- Orthopaedic Department, Athens Medical Center, 56, Kifisias ave and Delfon, 15125, Amaroussio, Athens, Greece
| | - Dimitrios Paschaloglou
- Orthopaedic Department, Athens Medical Center, 56, Kifisias ave and Delfon, 15125, Amaroussio, Athens, Greece
| | - Ioannis Tsarouchas
- Orthopaedic Department, Athens Medical Center, 56, Kifisias ave and Delfon, 15125, Amaroussio, Athens, Greece
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Middleton S, Toms A. Allergy in total knee arthroplasty: a review of the facts. Bone Joint J 2016; 98-B:437-41. [PMID: 27037424 DOI: 10.1302/0301-620x.98b4.36767] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 10/21/2015] [Indexed: 12/18/2022]
Abstract
We explored the literature surrounding whether allergy and hypersensitivity has a clinical basis for implant selection in total knee arthroplasty (TKA). In error, the terms hypersensitivity and allergy are often used synonymously. Although a relationship is present, we could not find any evidence of implant failure due to allergy. There is however increasing basic science that suggests a link between loosening and metal ion production. This is not an allergic response but is a potential problem. With a lack of evidence logically there can be no justification to use 'hypoallergenic' implants in patients who have pre-existing skin sensitivity to the metals used in TKA.
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Affiliation(s)
- S Middleton
- Royal Devon and Exeter Hospitals Foundation Trust, Barrack Rd, Exeter, EX2 5DW, UK
| | - A Toms
- Royal Devon and Exeter Hospitals Foundation Trust, Barrack Rd, Exeter, EX2 5DW, UK
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Abstract
Metal hypersensitivity in patients with a total knee arthroplasty (TKA) is a controversial topic. The diagnosis is difficult, given the lack of robust clinical validation of the utility of cutaneous and in vitro testing. Metal hypersensitivity after TKA is quite rare and should be considered after eliminating other causes of pain and swelling, such as low-grade infection, instability, component loosening or malrotation, referred pain, and chronic regional pain syndrome. Anecdotal observations suggest that two clinical presentations of metal hypersensitivity may occur after TKA: dermatitis or a persistent painful synovitis of the knee. Patients may or may not have a history of intolerance to metal jewelry. Laboratory studies, including erythrocyte sedimentation rate, C-reactive protein level, and knee joint aspiration, are usually negative. Cutaneous and in vitro testing have been reported to be positive, but the sensitivity and specificity of such testing has not been defined. Some reports suggest that, if metal hypersensitivity is suspected and nonsurgical measures have failed, then revision to components fabricated of titanium alloy or zirconium coating can be successful in relieving symptoms. Revision should be considered as a last resort, however, and patients should be informed that no evidence-based medicine is available to guide the management of these conditions, particularly for decisions regarding revision. Given the limitations of current testing methods, the widespread screening of patients for metal allergies before TKA is not warranted.
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Titanium niobium nitride knee implants are not inferior to chrome cobalt components for primary total knee arthroplasty. Arch Orthop Trauma Surg 2015; 135:1749-54. [PMID: 26318754 DOI: 10.1007/s00402-015-2320-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Metal allergy in total knee arthroplasty (TKA) is still a controversial topic. Oxinium, ceramic or titanium niobium nitride (TiNbN) coated implants are available for some knee systems. The hypothesis of this study was that the use of TiNbN-coated components would not lead to inferior results compared to conventional implants and that none of the allergic patients receiving TiNbN-coated implants would require revision for metal allergy. MATERIALS AND METHODS This study was a retrospective, 2 to 1 matched pairs study with 40 titanium niobium nitride-coated TKA compared with 80 conventional cobalt chrome implants. No demographic differences between these groups were observed. The mean follow-up for this study was 2 years. RESULTS No differences in clinical, radiological, or patient-reported outcome measurements were observed between the two groups. No patients have been revised at this short- to medium-term outcome evaluation. DISCUSSION Metal allergy leading to contact or systemic dermatitis is especially linked to chrome and cobalt allergy. Nickel allergy because of knee implants rarely gives cutaneous symptoms, but could potentially lead to peri-prosthetic osteolysis and loosening. The use of titanium niobium nitride implants in case of a positive history of metal allergy could avoid this devastating complication. CONCLUSION The use of titanium niobium nitride-coated implants for primary knee osteoarthritis shows similar clinical and radiological outcomes as conventional TKA without revision for loosening at short- to medium-term follow-up. Level of evidence Level IV study.
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27
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Biomaterial hypersensitivity: is it real? Supportive evidence and approach considerations for metal allergic patients following total knee arthroplasty. BIOMED RESEARCH INTERNATIONAL 2015; 2015:137287. [PMID: 25883940 PMCID: PMC4390183 DOI: 10.1155/2015/137287] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 09/19/2014] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Ashwin Rao
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
| | - M Ramam
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
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Thienpont E, Berger Y. No allergic reaction after TKA in a chrome-cobalt-nickel-sensitive patient: case report and review of the literature. Knee Surg Sports Traumatol Arthrosc 2013; 21:636-40. [PMID: 22488014 DOI: 10.1007/s00167-012-2000-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 03/29/2012] [Indexed: 10/28/2022]
Abstract
Hypersensitivity to metallic implants remains relatively unpredictable and poorly understood. Although 20-25 % of total joint arthroplasty patients develop metal sensitivity, only a few highly susceptible persons (<1 %) exhibit symptoms. We present a case report of a fifty-two-year-old woman with a preoperatively documented metal allergy who underwent bilateral total knee arthroplasty using a titanium-niobium-coated implant on one side and a chrome-cobalt implant on the other side because of a logistics problem. At 2-year follow-up, no clinical symptoms of allergy or loosening of the implant were observed. Level of evidence IV.
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Affiliation(s)
- Emmanuel Thienpont
- Department of Orthopaedic Surgery, Saint Luc University Hospital, Avenue Hippocrate 10, 1200, Brussels, Belgium.
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Marchalik D, Lipsky A, Petrov D, Harvell JD, Milgraum SS. Dermatologic Presentations of Orthopedic Pathologies. Am J Clin Dermatol 2012; 13:293-310. [DOI: 10.2165/11595880-000000000-00000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Cousen PJ, Gawkrodger DJ. Metal allergy and second-generation metal-on-metal arthroplasties. Contact Dermatitis 2011; 66:55-62. [DOI: 10.1111/j.1600-0536.2011.01970.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and systemic hypersensitivity reactions to metallic implants. Dermatitis 2011. [PMID: 21504692 DOI: 10.2310/6620.2011.10055] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cutaneous reactions to metal implants, orthopedic or otherwise, are well documented in the literature. The first case of a dermatitis reaction over a stainless steel fracture plate was described in 1966. Most skin reactions are eczematous and allergic in nature, although urticarial, bullous, and vasculitic eruptions may occur. Also, more complex immune reactions may develop around the implants, resulting in pain, inflammation, and loosening. Nickel, cobalt, and chromium are the three most common metals that elicit both cutaneous and extracutaneous allergic reactions from chronic internal exposure. However, other metal ions as well as bone cement components can cause such hypersensitivity reactions. To complicate things, patients may also develop delayed-type hypersensitivity reactions to metals (ie, in-stent restenosis, prosthesis loosening, inflammation, pain, or allergic contact dermatitis) following the insertion of intravascular stents, dental implants, cardiac pacemakers, or implanted gynecologic devices. Despite repeated attempts by researchers and clinicians to further understand this difficult area of medicine, the association between metal sensitivity and cutaneous allergic reactions remains to be fully understood. This review provides an update of the current knowledge in this field and should be valuable to health care providers who manage patients with conditions related to this field.
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Bewsher SM, Kurzydlo AM, Gillespie RJ. Idiopathic post-traumatic dermatitis at the site of recent joint replacement. Contact Dermatitis 2007; 58:54-5. [PMID: 18154563 DOI: 10.1111/j.1600-0536.2007.01163.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Idiopathic dermatitis over the site of previous trauma is a recognized but infrequently reported phenomenon that provides a diagnostic dilemma. Careful investigation is needed in order to exclude other rare and/or treatable causes.
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Affiliation(s)
- S M Bewsher
- Department of Dermatology, Royal Newcastle Centre, Newcastle, New South Wales, Australia 2305.
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