Metal allergy in total-joint arthroplasty

Abstract

Rationale:Due to the low incidence and lack of effective diagnostic measures for the diagnosis of metal allergy in patients undergoing total joint arthroplasty (TJA), diagnosis relies mainly on the exclusion of other causes, in particular infection. It remains a relatively unpredictable and poorly understood cause of implant failure. At present, skin patch testing, leukocyte migration inhibition test (LMIT) and lymphocyte transformation tests (LTT) are being commonly used to assess metal hypersensitivity.This report presents both a case and literature review.Patient concerns:A 61-year-old female patient experienced continuous swelling and pain in the right knee joint for 9 months after a right-side total knee arthroplasty (TKA).Diagnoses:We believe this is the case report of metal allergy in TKA. The following were the reasons for this. First, no definite symptoms of infection during revision arthroplasty were observed, but with obvious hyperplasia of synovium. Furthermore, a frozen biopsy revealed an extremely low neutrophil count, which was considered to be caused by chronic inflammation. Second, the results of repeated post-operation reexaminations indicate a clear increase in the number of eosinophils, while no bacteria were found in the tissue bacterial smear performed during the operation. Third, improvements were clearly observed in the patient following synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment.Interventions:The patient underwent synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment.Outcomes:The patient's right knee remained mildly swollen; however, the pain has been relieved significantly. The range of motion could achieve 0 degrees of extension and 90 degrees of flexion.Lessons:No consensus has been reached about the best diagnostic criteria for this disease, and most physicians would consider it to be a possibility when other diseases including periprosthetic joint infection (PJI) have been excluded. Although this case followed the same course, the outcome following synovectomy and anti-anaphylactic treatment further confirmed our hypothesis.

Improved outcomes in patients with positive metal sensitivity following revision total knee arthroplasty

“…The results of this study are in agreement with several case reports in the literature Caicedo et al demonstrated a significant percentage of patients that had undergone total joint arthroplasty and had unexplained joint pain were hypersensitive to implant metals [24]. Bao et al presented a case report in which a patient with continuous swelling of their total knee arthroplasty showed significant improvement after a synovectomy and component revision [25]. Overall, in the absence of obvious etiology, patients presenting with pain, decreased range of motion, and even contact dermatitis-like reactions have resolution of their symptoms after revision to a hypoallergenic component.…”

Metal Hypersensitivity in Joint Arthroplasty

“…A high prevalence of contact allergies to metals exists with up to 24.4% to nickel, 8.8% to cobalt, 5.9% to chromium, and 0.2% to 3% to Titanium. 10 , 11 It is thought that jewelry is the most common cause of exposure, but patients can be exposed to metal in various ways. 12 This can occur through the skin in the form of cell-phones, clothing fasteners, and leather.…”

The Migratory Cortical Button: A Rare Case of Hypersensitivity to Titanium after an Anterior Cruciate Ligament Reconstruction

“…In particular, atopic dermatitis concerns 15% to 20% of adults in Northern Europe. The prevalence of cutaneous metal hypersensitivity in the population is between 10% and 15% in descending order: nickel, cobalt, and chromium2,3). This prevalence could increase to 25% for patients with a metal implant with a good functional result and to 60% for those with a poor functional result2,4).…”

“…The prevalence of cutaneous metal hypersensitivity in the population is between 10% and 15% in descending order: nickel, cobalt, and chromium2,3). This prevalence could increase to 25% for patients with a metal implant with a good functional result and to 60% for those with a poor functional result2,4). The concept of hypersensitivity to metallic orthopedic implants was introduced in the late 90s3) and can cause pain, aseptic loosening and synovial reactions even though the link between symptoms and allergy remains uncertain.…”

“…If symptoms do not improve or become severe, surgery may be needed. Titanium is the best option for implants in case of revision, and the concept of “hypersensitivity-friendly” implants (made of titanium alloy or zirconium)2) has recently been developed. If the patient has an allergy to titanium or titanium alloys, another option must obviously be chosen.…”