Allergy in total knee replacement surgery: Is it a real problem?

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.

Identification of pigments related to allergic tattoo reactions in 104 human skin biopsies

“…38,39 Metal allergy due to metal joint replacement is considered rare despite the huge amount of nickel and chromium present in these prostheses. 40,41 Still, the rate of patients sensitized to metals is higher among those with implant failure. 42 Thus metal deposition in the body does not necessarily lead to adverse effects, but may still play a role during local inflammatory responses due to their high local concentrations in tissue surrounding joints with implants.…”

“…Soluble metal ions may induce allergy (eg, nickel ions) and are considered to be constantly cleared from tissues with a short half‐life in the body, for example, 17–39 hours for clearance of nickel ions measured in the urine after single dose intake . Metal allergy due to metal joint replacement is considered rare despite the huge amount of nickel and chromium present in these prostheses . Still, the rate of patients sensitized to metals is higher among those with implant failure .…”

Efficacy of postoperative drainage in total knee arthroplasty: Review of the literature

“… 2-4 The focus is on many variables that can affect the outcomes of TKA, including preoperative clinical plan, implantation technique, selection of implant materials and intra- and postoperative strategies. 5-6 …”

Early Outcomes of an Alternative Bearing Surface in Primary Total Knee Arthroplasty in Patients with Self-reported Metal Allergy

“…The patch test is the most frequently used method to diagnose metal hypersensitivity reactions but faces significant controversy because of its specificity and sensitivity [7], and questions arise regarding the correlation of dermatologic metal sensitivity and deep peri-implant sensitivity [8][9][10][11]. Many in vivo tests such as lymphocyte transformation test (LTT), modified lymphocyte stimulation test, and leukocyte migration inhibition test (LMIT) have been developed, which have improved sensitivity but are timely and expensive and yield false-positive results [12]. To add to this dilemma, Yang et al [13] demonstrated the LTT not to correlate with prerevision or postrevision functional scoring or even histopathologic assessments taken intraoperatively.…”