Metal Hypersensitivity in Total Joint Arthroplasty

Eftekhary, Nima; Shepard, Nicholas; Wiznia, Daniel H.; Iorio, Richard; Long, William J.; Vigdorchik, Jonathan M.

doi:10.2106/jbjs.rvw.17.00169

Cited by 12 publications

(12 citation statements)

References 51 publications

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“…Facing the depicted drastic course of routine joint replacement vigorously illustrates the need for advanced metal hypersensitivity diagnostics and their integration into clinical decision making. Recently, another diagnostic algorithm related to the one suggested in this report, has been proposed (26). An important part of that algorithm is the initial exclusion of PJI and mechanical complications.…”

Section: Discussionmentioning

confidence: 99%

Diagnosis of Metal Hypersensitivity in Total Knee Arthroplasty: A Case Report

et al. 2019

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Delayed type hypersensitivity (DTH) reactions are considered infrequent complications in arthroplasty, but have been recognized to be associated with devastating morbidity and substantial decrease in quality of life of affected patients. Chronic inflammation of artificial joints and associated loss of peri-implant bone often require revision surgery. Methods for the diagnosis of implant-related DTH are available but infrequently considered to the full extent. Sequential diagnostics based on exclusion of septic complications, local and systemic metal level determination, lymphocyte transformation testing (LTT), and local T cell subset analysis are required for an unequivocal DTH diagnosis. Here, we report on a patient with a history of chronic rheumatoid arthritis and an unfavorable outcome of unilateral knee arthroplasty. This case illustrates pitfalls and difficulties in the course of recurrent inflammation following joint replacement. In the early course, suspicion of low-grade bacterial infection led to three two-stage revisions. Afterwards, the joint was proven to be sterile. However, metal level quantification revealed release of especially cobalt and chromium from the joint, LTT indicated persisting cobalt and nickel sensitization and subset analysis of T cells from the synovium suggested DTH as a root cause for the inflammatory symptoms. This report aims to recommend the depicted diagnostic algorithm as an adequate tool for future DTH detection. Yet, systemic to local subset ratios for effector memory and regulatory T cells should be derived from sufficient patient numbers to establish it as a diagnostic marker. Moreover, future prospects regarding implant-related DTH diagnostics are discussed. Therapeutic options for the portrayed patient are proposed, considering pharmaceutical, cell-therapeutic and surgical aspects. Patients who experience peri-implant inflammation but do not have obvious mechanical or infectious problems remain a diagnostic challenge and are at high risk of being treated inadequately. Since potentially sensitizing materials are regularly used in arthroplasty, it is essential to detect cases of acute DTH-derived inflammation of an artificial joint at early postoperative stages. This would reduce the severity of inflammation-related long-term consequences for affected patients and may avoid unnecessary revision surgery.

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Section: Discussionmentioning

confidence: 99%

Diagnosis of Metal Hypersensitivity in Total Knee Arthroplasty: A Case Report

et al. 2019

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“…Thus, typical signs and symptoms of PJI as well as of hypersensitivity include local swelling, erythema, warmth, pain, and functional deficit of the affected joint. Therefore, arthroplasty implant-related hypersensitivity has remained a diagnosis of exclusion (31). Appropriate workup must always be guided by thorough differential diagnostic thinking, directed history taking, and physical examination.…”

Section: Hypersensitivity Reactions In Orthopedicsmentioning

confidence: 99%

“…This imbalance is typical for osteolysis and promotes implant loosening (62). Depending on the strength of a cellular response to the antigen the respective time frame may vary from weeks to years, with only some patients showing severe allergic reactions (31). Allergies and hypersensitivity are highly individual processes and depend on multiple factors (Figure 2).…”

Section: Adding Up the Piecesmentioning

confidence: 99%

The Allergic Bone Marrow? The Immuno-Capacity of the Human Bone Marrow in Context of Metal-Associated Hypersensitivity Reactions

et al. 2019

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Arthroplasty ranks among the greatest achievements of surgical medicine, with total hip replacement termed “the operation of the century.” Despite its wide success, arthroplasty bears risks, such as local reactions to implant derived wear and corrosion products. Prevalence of allergies across Western society increases and along the number of reported hypersensitivity reactions to orthopedic implant materials. In this context the main focus is on delayed hypersensitivity (DTH). This mechanism is mainly attributed to T cells and an overreaction of the adaptive immune system. Arthroplasty implant materials are in direct contact with bone marrow (BM), which is discussed as a secondary lymphoid organ. However, the mechanisms of sensitization toward implant wear remain elusive. Nickel and cobalt ions can form haptens with native peptides to activate immune cell receptors and are therefore common T helper allergens in cutaneous DTH. The rising prevalence of metal-related allergy in the general population and evidence for the immune-modulating function of BM allow for the assumption hypersensitivity reactions could occur in peri-implant BM. There is evidence that pro-inflammatory factors released during DTH reactions enhance osteoclast activity and inhibit osteoblast function, an imbalance characteristic for osteolysis. Even though some mechanisms are understood, hypersensitivity has remained a diagnosis of exclusion. This review aims to summarize current views on the pathomechanism of DTH in arthroplasty with emphasis on BM and discusses recent advances and future directions for basic research and clinical diagnostics.

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“…In the study by Hallab et al, 25-60% of patients with well-functioning total hip arthroplasty or TKA had positive skin patch testing (SPT) for metal allergy [ 4 , 5 ]. Although patient-reported allergies, including patient-reported metal allergies, have been identified as negative prognostic indicators, there are currently no objective measures that have been shown to diagnose an immune reaction to a prosthetic joint or predict outcomes in patients with metal sensitivity [ 6 , 7 ].…”

Section: Introductionmentioning

confidence: 99%

“…Patients with a suspected allergic reaction after TKA may present with an eczematous dermatitis or persistent painful synovitis, effusion, and stiffness [ 7 ]. Symptoms typically present 2 months to 2 years after TKA and are more common in females [ 8 ].…”

Section: Introductionmentioning

confidence: 99%