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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References
Anand A, McGlynn F, Jiranek W. Metal hypersensitivity: can it mimic infection? The Journal of Arthroplasty. 2009; 24(5): 826.e25-8.
Atanaskova Mesinkovska N, Tellez A, Molina L, et al. The effect of patch testing on surgical practices and outcomes in orthopedic patients with metal implants. Archives of Dermatology. 2012; 148(6): 687-93.
Australian O. Association, Annual Report 2014. 2014.
Bader R, Bergschmidt P, Fritsche A, Ansorge S, Thomas P, Mittelmeier W. Alternative materials and solutions in total knee arthroplasty for patients with metal allergy. Der Orthopade. 2008; 37(2): 136-42.
Bader R, Mittelmeier W, Steinhauser E. Failure analysis of total knee replacement. Basics and methodological aspects of the damage analysis. Der Orthopade. 2006; 35(9): 896. 8-900, 2-3.
Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and systemic hypersensitivity reactions to metallic implants. Dermatitis : Contact, Atopic, Occupational, Drug. 2011; 22(2): 65-79.
Beecker J, Gordon J, Pratt M. An interesting case of joint prosthesis allergy. Dermatitis : Contact, Atopic, Occupational, Drug. 2009; 20(2): E4-9.
Bergschmidt P, Bader R, Kluess D, et al. Total knee replacement system with a ceramic femoral component versus two traditional metallic designs: a prospective short-term study. Journal of Orthopaedic Surgery (Hong Kong). 2013; 21(3): 294-9.
Bergschmidt P, Bader R, Mittelmeier W. Metal hypersensitivity in total knee arthroplasty: revision surgery using a ceramic femoral component - a case report. The Knee. 2012; 19(2): 144-7.
Bergschmidt PB, Bader R, Ganzer D, et al. Ceramic Femoral Components in Total Knee Arthroplasty - Two Year Follow-Up Results of an International Prospective Multi-Centre Study. The Open Orthopaedics Journal. 2012; 6: 172-8.
Bloemke AD, Clarke HD. Prevalence of Self-Reported Metal Allergy in Patients Undergoing Primary Total Knee Arthroplasty. The Journal of Knee Surgery. 2015; 28(3): 243-6.
Buchanan RA, Rigney ED Jr, Williams JM. Wear-accelerated corrosion of Ti-6Al-4V and nitrogen-ion-implanted Ti-6Al-4V: mechanisms and influence of fixed-stress magnitude. Journal of Biomedical Materials Research. 1987; 21(3): 367-77.
Carlsson A, Moller H. Implantation of orthopaedic devices in patients with metal allergy. Acta Dermato-Venereologica. 1989; 69(1): 62-6.
Carlsson AS, Magnusson B, Moller H. Metal sensitivity in patients with metal-to-plastic total hip arthroplasties. Acta Orthopaedica Scandinavica. 1980; 51(1): 57-62.
Carulli C, Villano M, Bucciarelli G, Martini C, Innocenti M. Painful knee arthroplasty: definition and overview. Clinical Cases in Mineral and Bone Metabolism : The Official Journal of The Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases. 2011; 8(2): 23-5.
Dietrich KA, Mazoochian F, Summer B, Reinert M, Ruzicka T, Thomas P. Intolerance reactions to knee arthroplasty in patients with nickel/cobalt allergy and disappearance of symptoms after revision surgery with titanium-based endoprostheses. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG. 2009; 7(5): 410-3.
Eben R, Dietrich KA, Nerz C, et al. Contact allergy to metals and bone cement components in patients with intolerance of arthroplasty. Deutsche Medizinische Wochenschrift (1946). 2010; 135(28-29): 1418-22.
Edwards SA, Gardiner J. Hypersensitivity to benzoyl peroxide in a cemented total knee arthroplasty: cement allergy. The Journal of Arthroplasty. 2007; 22(8): 1226-8.
Elves MW, Wilson JN, Scales JT, Kemp HB. Incidence of metal sensitivity in patients with total joint replacements. British Medical Journal. 1975; 4(5993): 376-8.
Evans EM, Freeman MA, Miller AJ, Vernon-Roberts B. Metal sensitivity as a cause of bone necrosis and loosening of the prosthesis in total joint replacement. J Bone Joint Surg Br. 1974; 56-b(4): 626-42.
Fink U. Safety aspects in the coating of titanium slide components. Der Orthopade. 1997; 26(2): 160-5.
Frigerio E, Pigatto PD, Guzzi G, Altomare G. Metal sensitivity in patients with orthopaedic implants: a prospective study. Contact Dermatitis. 2011; 64(5): 273-9.
Gallo J, Goodman SB, Konttinen YT, Wimmer MA, Holinka M. Osteolysis around total knee arthroplasty: a review of pathogenetic mechanisms. Acta Biomaterialia. 2013; 9(9): 8046-58.
Gao X, He RX, Yan SG, Wu LD. Dermatitis associated with chromium following total knee arthroplasty. The Journal of Arthroplasty. 2011; 26(4): 665.e13-6.
Granchi D, Cenni E, Tigani D, Trisolino G, Baldini N, Giunti A. Sensitivity to implant materials in patients with total knee arthroplasties. Biomaterials. 2008; 29(10): 1494-500.
Graves CM, Otero JE, Gao Y, Goetz DD, Willenborg MD, Callaghan JJ. Patient reported allergies are a risk factor for poor outcomes in total hip and knee arthroplasty. The Journal of Arthroplasty. 2014; 29(9 Suppl): 147-9.
Haeberle M, Wittner B. Is gentamicin-loaded bone cement a risk for developing systemic allergic dermatitis? Contact Dermatitis. 2009; 60(3): 176-7.
Hallab NJ, Caicedo M, Finnegan A, Jacobs JJ. Th1 type lymphocyte reactivity to metals in patients with total hip arthroplasty. Journal of Orthopaedic Surgery and Research. 2008; 3: 6.
Handa S, Dogra S, Prasad R. Metal sensitivity in a patient with a total knee replacement. Contact Dermatitis. 2003; 49(5): 259-60.
Harman MK, Banks SA, Hodge WA. Wear Analysis of a Retrieved Hip Implant With Titanium Nitride Coating. The Journal of Arthroplasty. 1997; 12(8): 938-45.
Hendry JA, Pilliar RM. The fretting corrosion resistance of PVD surface-modified orthopedic implant alloys. Journal of Biomedical Materials Research. 2001; 58(2): 156-66.
Hofer JK, Ezzet KA. A minimum 5-year follow-up of an oxidized zirconium femoral prosthesis used for total knee arthroplasty. The Knee. 2014; 21(1): 168-71.
Innocenti M, Carulli C, Matassi F, Carossino AM, Brandi ML, Civinini R. Total knee arthroplasty in patients with hypersensitivity to metals. International Orthopaedics. 2014; 38(2): 329-33.
Kaplan K, Della Valle CJ, Haines K, Zuckerman JD. Preoperative identification of a bone-cement allergy in a patient undergoing total knee arthroplasty. The Journal of Arthroplasty. 2002; 17(6): 788-91.
Krecisz B, Kiec-Swierczynska M, Bakowicz-Mitura K. Allergy to metals as a cause of orthopedic implant failure. International Journal of Occupational Medicine and Environmental Health. 2006; 19(3): 178-80.
Krenn V, Morawietz L, Kienapfel H, et al. Revised consensus classification. Histopathological classification of diseases associated with joint endoprostheses. Zeitschrift fur Rheumatologie. 2013; 72(4): 383-92.
Krenn V, Morawietz L, Perino G, et al. Revised histopathological consensus classification of joint implant related pathology. Pathology, Research and Practice. 2014; 210(12): 779-86.
Lappalainen R, Santavirta SS. Potential of Coatings in Total Hip Replacement. Clinical Orthopaedics and Related Research. 2005; 430: 72-9.
Lieberman P, Fonacier L. Systemic contact dermatitis possibly related to metal implants. The Journal of Allergy and Clinical Immunology In Practice. 2014; 2(4): 487.
Lutzner J, Hartmann A, Dinnebier G, Spornraft-Ragaller P, Hamann C, Kirschner S. Metal hypersensitivity and metal ion levels in patients with coated or uncoated total knee arthroplasty: a randomised controlled study. International Orthopaedics. 2013; 37(10): 1925-31.
McLawhorn AS, Bjerke-Kroll BT, Blevins JL, Sculco PK, Lee YY, Jerabek SA. Patient-Reported Allergies Are Associated With Poorer Patient Satisfaction and Outcomes After Lower Extremity Arthroplasty: A Retrospective Cohort Study. The Journal of Arthroplasty. 2015; 30(7): 1132-6.
Meyer H, Kruger A, Roessner A, Lohmann CH. Allergic reactions as differential diagnosis for periprosthetic infection. Der Orthopade. 2012; 41(1): 26-31.
Mitchelson AJ, Wilson CJ. Biomaterial Hypersensitivity: Is It Real? Supportive Evidence and Approach Considerations for Metal Allergic Patients following Total Knee Arthroplasty. BioMed Research International. 2015; 2015: 137287.
Morawietz L, Krenn V. The spectrum of histomorphological findings related to joint endoprosthetics. Der Pathologe. 2014; 35 Suppl 2: 218-24.
Munch HJ, Jacobsen SS, Olesen JT, et al. The association between metal allergy, total knee arthroplasty, and revision: study based on the Danish Knee Arthroplasty Register. Acta Orthopaedica. 2015; 86(3): 378-83.
Nasser S. Orthopedic metal immune hypersensitivity. Orthopedics. 2007; 30(8 Suppl): 89-91.
Niki Y, Matsumoto H, Otani T, et al. Screening for symptomatic metal sensitivity: a prospective study of 92 patients undergoing total knee arthroplasty. Biomaterials. 2005; 26(9): 1019-26.
Pellengahr C, Mayer W, Maier M, et al. Resurfacing knee arthroplasty in patients with allergic sensitivity to metals. Archives of Orthopaedic and Trauma Surgery. 2003; 123(4): 139-43.
Post ZD, Orozco FR, Ong AC. Metal sensitivity after TKA presenting with systemic dermatitis and hair loss. Orthopedics. 2013; 36(4): e525-8.
Raimondi MT, Pietrabissa R. The in-vivo wear performance of prosthetic femoral heads with titanium nitride coating. Biomaterials. 2000; 21(9): 907-13.
Rau C, Thomas P, Thomsen M. Metal sensitivity in patients with joint replacement arthroplasties before and after surgery. Der Orthopade. 2008; 37(2): 102-10.
Reed KB, Davis MD, Nakamura K, Hanson L, Richardson DM. Retrospective evaluation of patch testing before or after metal device implantation. Archives of Dermatology. 2008; 144(8): 999-1007.
Schalock PC, Menne T, Johansen JD, et al. Hypersensitivity reactions to metallic implants - diagnostic algorithm and suggested patch test series for clinical use. Contact Dermatitis. 2012; 66(1): 4-19.
Schuh A, Lill C, Honle W, Effenberger H. Prevalence of allergic reactions to implant materials in total hip and knee arthroplasty. Zentralblatt fur Chirurgie. 2008; 133(3): 292-6.
Schuh A, Thomas P, Reinhold R, Holzwarth U, Zeiler G, Mahler V. Allergic reaction to components of bone cement after total knee arthroplasty. Zentralblatt fur Chirurgie. 2006; 131(5): 429-31.
Smith&Nephew. www.smith-nephew.com. 2012. Available from: http://www.smith-nephew.com/key-products/orthopaedic-reconstruction/oxinium-oxidized-zirconium/.
Streicher RM, Weber H, Schon R, Semlitsch M. New surface modification for Ti-6Al-7Nb alloy: oxygen diffusion hardening (ODH). Biomaterials. 1991; 12(2): 125-9.
Thakur RR, Ast MP, McGraw M, Bostrom MP, Rodriguez JA, Parks ML. Severe persistent synovitis after cobalt-chromium total knee arthroplasty requiring revision. Orthopedics. 2013; 36(4): e520-4.
Thienpont E, Berger Y. No allergic reaction after TKA in a chrome-cobalt-nickel-sensitive patient: case report and review of the literature. Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of The ESSKA. 2013; 21(3): 636-40.
Thomas P, Summer B, Krenn V, Thomsen M. Allergy diagnostics in suspected metal implant intolerance. Der Orthopade. 2013; 42(8): 602-6.
Thomas P, von der Helm C, Schopf C, et al. Patients with Intolerance Reactions to TKA: Combined Assessment of Allergy Diagnostics, Periprosthetic Histology, and Peri-implant Cytokine Expression Pattern. BioMed Research International. 2014; 2014: 910156.
Thomsen M, Rozak M, Thomas P. Pain in a chromium-allergic patient with total knee arthroplasty: disappearance of symptoms after revision with a special surface-coated TKA--a case report. Acta Orthopaedica. 2011; 82(3): 386-8.
Thomsen M, Rozak M, Thomas P. Use of allergy implants in Germany: results of a survey. Der Orthopade. 2013; 42(8): 597-601.
van Hove RP, Sierevelt IN, van Royen BJ, Nolte PA. Titanium-Nitride Coating of Orthopaedic Implants: A Review of the Literature. BioMed Research International. 2015; 2015: 485975.
Van Opstal N, Verheyden F. Revision of a tibial baseplate using a customized oxinium component in a case of suspected metal allergy. A case report. Acta Orthopaedica Belgica. 2011; 77(5): 691-5.
Verma SB, Mody B, Gawkrodger DJ. Dermatitis on the knee following knee replacement: a minority of cases show contact allergy to chromate, cobalt or nickel but a causal association is unproven. Contact Dermatitis. 2006; 54(4): 228-9.
Waterman AH, Schrik JJ. Allergy in hip arthroplasty. Contact Dermatitis. 1985; 13(5): 294-301.
Witzleb WC, Hanisch U, Kolar N, Krummenauer F, Guenther KP. Neo-capsule tissue reactions in metal-on-metal hip arthroplasty. Acta Orthopaedica. 2007; 78(2): 211-20.
Zeng Y, Feng W, Li J, et al. A prospective study concerning the relationship between metal allergy and post-operative pain following total hip and knee arthroplasty. International Orthopaedics. 2014; 38(11): 2231-6.
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Martin Faschingbauer, MD reports other from Deutsche Forschungsgemeinschaft, during the conduct of the study. Lisa Renner, MD has declared that she has no conflict of interest. Friedrich Boettner, MD reports personal fees from Smith & Nephew, during the conduct of the study; personal fees from Ortho Development, outside the work.
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Faschingbauer, M., Renner, L. & Boettner, F. Allergy in Total Knee Replacement. Does It Exist?. HSS Jrnl 13, 12–19 (2017). https://doi.org/10.1007/s11420-016-9514-8
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DOI: https://doi.org/10.1007/s11420-016-9514-8