Keith Kotecki¹, John Walsh¹, Gary Ulrich²*, Jim Christensen^1,3 and Ronald Hillock^1,4

¹Valley Hospital Orthopedic Surgery Residency Program, Valley Hospital Medical Center, Las Vegas, NV, USA
²Department of Orthopedic Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
³Department of Allergy and Immunology, Optum Care, Las Vegas, NV, USA
⁴Department of Orthopedic Surgery, Nevada Orthopedic and Spine Center, Las Vegas, NV, USA

*Corresponding Author: Gary Ulrich, Department of Orthopedic Surgery, University of Kentucky College of Medicine, Lexington, KY, USA.

Received: January 23, 2023; Published: March 13, 2023

Abstract

Background: Failed total joint arthroplasty (TJA) is a multifactorial problem and one potential cause of failed TJA has been attributed to allergic reaction to the metallic components of the implants. The pathophysiology of implant function failure due to allergy has been postulated but is poorly understood. This review explores recent literature on the topic of metal hypersensitivity in TJA and human implantation in general to clarify the current state of understanding on this topic.

Methods: A literature search was completed via PubMed for all articles published related to implant failure in TJA due to metallic allergic reaction. The information was then sorted for relevance on basic science as well as clinical outcomes attributed to metal allergy in TJA.

Results: This review found that previous works attribute 5% of failed TJA to metal hypersensitivity reactions, no single test or finding has been found to be predictive of patients who will experience a failed TJA due to metal hypersensitivity, and there is no clear relationship between metal hypersensitivity and poor clinical outcomes in TJA although many theories have been presented.

Discussion: While evidence-based evaluation and management is desired for metal hypersensitivity, no clear consensus exists. Even routine pre-implantation testing has not shown to be of benefit. Furthermore, no test or finding has been shown to be diagnostic of metal allergy as a cause of failed TJA after implantation. Based on review of the published literature, this review article finds no objective evidence of metal allergy as a cause of TJA failure and therefore cannot conclude that metal allergic reaction is a mode of failure in TJA.

Keywords: Metal Hypersensitivity; Metal Allergy; Metal Ions; Allergic Reaction; Joint Arthroplasty

References

1. Ulrich Slif D., et al. "Total hip arthroplasties: what are the reasons for revision?" International Orthopaedics5 (2008): 597-604.
2. Sloan Matthew., et al. "Projected volume of primary total joint arthroplasty in the US, 2014 to 2030”. JBJS17 (2018): 1455-1460.
3. Heyse Thomas J., et al. "Total knee arthroplasty in patients with juvenile idiopathic arthritis”. Clinical Orthopaedics and Related Research^®1 (2014): 147-154.
4. Mahomed Nizar N., et al. "Rates and outcomes of primary and revision total hip replacement in the United States medicare population”. JBJS1 (2003): 27-32.
5. Bourne Robert B., et al. "Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?” Clinical Orthopaedics and Related Research^®1 (2010): 57-63.
6. Jones C Allyson., et al. "Total joint arthroplasties: current concepts of patient outcomes after surgery”. Rheumatic Disease Clinics of North America1 (2007): 71-86.
7. Kręcisz Beata Marta Kieć-Świerczyńska and Dorota Chomiczewska-Skóra. "Allergy to orthopedic metal implants-a prospective study”. International Journal of Occupational Medicine and Environmental Health4 (2012): 463-469.
8. Büdinger Lioba., et al. "Immunologic mechanisms in hypersensitivity reactions to metal ions: an overview”. Allergy2 (2000): 108-115.
9. Loyo Esthela., et al. "Autoimmunity in connection with a metal implant: a case of autoimmune/autoinflammatory syndrome induced by adjuvants”. Autoimmunity Highlights1 (2013): 33-38.
10. Basko-Plluska Juliana L., et al. "Cutaneous and systemic hypersensitivity reactions to metallic implants”. Dermatitis2 (2011): 65-79.
11. Giesinger Johannes M., et al. "Association of psychological status and patient-reported physical outcome measures in joint arthroplasty: a lack of divergent validity”. Health and Quality of Life Outcomes1 (2013): 1-6.
12. Nam, Denis, et al. "Patient-reported metal allergy: a risk factor for poor outcomes after total joint arthroplasty?”. The Journal of Arthroplasty9 (2016): 1910-1915.
13. Tzeng Nian-Sheng., et al. "Increased risk of psychiatric disorders in allergic diseases: a nationwide, population-based, cohort study”. Frontiers in Psychiatry(2018): 133.
14. Perruccio Anthony V., et al. "Importance of self‐rated health and mental well‐being in predicting health outcomes following total joint replacement surgery for osteoarthritis”. Arthritis Care and Research7 (2011): 973-981.
15. Browne James A., et al. "Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study”. The Journal of Arthroplasty3 (2014): 481-483.
16. Munro‐Ashman D and AJ Miller. "Rejection of metal to metal prosthesis and skin sensitivity to cobalt”. Contact Dermatitis2 (1976): 65-67.
17. Phillips JE., et al. "The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey”. The Journal of bone and joint surgery. British Volume7 (2006): 943-948.
18. Betsch Belinda Y., et al. "Treatment of joint prosthesis infection in accordance with current recommendations improves outcome”. Clinical Infectious Diseases8 (2008): 1221-1226.
19. Luetzner Joerg., et al. "Serum metal ion exposure after total knee arthroplasty”. Clinical Orthopaedics and Related Research (1976-2007)461 (2007): 136-142.
20. Hennig FF., et al. "Nickel-, chrom-and cobalt-concentrations in human tissue and body fluids of hip prosthesis patients”. Journal of Trace Elements and Electrolytes in Health and Disease4 (1992): 239-243.
21. Innocenti Massimo., et al. "Total knee arthroplasty in patients with hypersensitivity to metals”. International Orthopaedics2 (2014): 329-333.
22. , et al. "Patch tests”. Anais Brasileiros De Dermatologia88 (2013): 879-888.
23. Bravo Dalibel., et al. "No increased risk of knee arthroplasty failure in patients with positive skin patch testing for metal hypersensitivity: a matched cohort study”. The Journal of Arthroplasty8 (2016): 1717-1721.
24. Granchi Donatella., et al. "Sensitivity to implant materials in patients undergoing total hip replacement”. Journal of Biomedical Materials Research Part B: Applied Biomaterials: An Official Journal of The Society for Biomaterials, The Japanese Society for Biomaterials, and The Australian Society for Biomaterials and the Korean Society for Biomaterials2 (2006): 257-264.
25. Carlsson A and H Möller. "Implantation of orthopaedic devices in patients with metal allergy”. Acta Dermato-Venereologica1 (1989): 62-66.
26. Webley M., et al. "Metal sensitivity in patients with a hinge arthroplasty of the knee”. Annals of the Rheumatic Diseases4 (1978): 373-375.
27. Pichler WJ and J Tilch. "The lymphocyte transformation test in the diagnosis of drug hypersensitivity”. Allergy8 (2004): 809-820.
28. Ständer Sascha., et al. "Evaluation of lymphocyte transformation tests as compared with patch tests in nickel allergy diagnosis”. Contact Dermatitis4 (2017): 228-234.
29. Thomas Peter., et al. "Arthroplasty patients and nickel sensitization: What do patch test and lymphocyte transformation test tell us”. Seminars in Arthroplasty4 (2013).
30. Valentine-Thon., et al. "Validity of MELISA^® for metal sensitivity testing”. Neuroendocrinology Letters1/2 (2003): 57-64.
31. Valentine-Thon., et al. "LTT-MELISA (R) is clinically relevant for detecting and monitoring metal sensitivity”. Neuroendocrinology Letters1 (2006): 17-24.
32. King TC. "Inflammation, Inflammatory Mediators, and Immune-Mediated Disease-ScienceDirect”. (2007): 21-57.
33. Black J., et al. "Metallosis associated with a stable titanium-alloy femoral component in total hip replacement. A case report”. JBJS1 (1990): 126-130.
34. Watters Tyler Steven., et al. "Aseptic lymphocyte-dominated vasculitis-associated lesion: a clinicopathologic review of an underrecognized cause of prosthetic failure”. American Journal of Clinical Pathology6 (2010): 886-893.
35. Middleton S and Andrew Toms. "Allergy in total knee arthroplasty: a review of the facts”. The Bone and Joint Journal4 (2016): 437-441.
36. Verilast - Oxidized Zirconium with XLPE”. Smith and Nephew, Inc. (2014).
37. Advanced Surface Technology. Aesculap Implant Systems (2023).
38. Medacta SesiniTiN data on file. Medacta International (2023).
39. DOT America Medical Implant Solutions (2022).
40. Ceramic ball heads. BIOLOX Inside (2017).
41. Bergschmidt Philipp., et al. "Ceramic femoral components in total knee arthroplasty-two year follow-up results of an international prospective multi-centre study”. The Open Orthopaedics Journal6 (2012): 172.
42. Ajwani Sanil Harji and Charalambos P Charalambous. "Availability of total knee arthroplasty implants for metal hypersensitivity patients”. Knee Surgery and Related Research4 (2016): 312.
43. Merritt Katharine and Juan J Rodrigo. "Immune response to synthetic materials: sensitization of patients receiving orthopaedic implants”. Clinical Orthopaedics and Related Research (1976-2007)326 (1996): 71-79.
44. Klontz Karl C and William I Smith. "Acute Metallosis Following Total Knee Replacement-A Case Report”. Journal of Orthopaedic Case Reports1 (2014): 21.
45. Hallab Nadim., et al. "Hypersensitivity to metallic biomaterials: a review of leukocyte migration inhibition assays”. Biomaterials13 (2000): 1301-1314.
46. Merritt Katharine and Stanley A Brown. "Tissue reaction and metal sensitivity: an animal study”. Acta Orthopaedica Scandinavica1-6 (1980): 403-411.
47. Wang Kehui., et al. "Validation and comparison of luminex multiplex cytokine analysis kits with ELISA: determinations of a panel of nine cytokines in clinical sample culture supernatants”. Journal of Reproductive Immunology2 (2005): 175-191.
48. Carossino Anna Maria., et al. "Hypersensitivity reactions to metal implants: laboratory options”. BMC Musculoskeletal Disorders1 (2016): 1-14.

Citation

Citation: Gary Ulrich., et al. “Metal Hypersensitivity in Total Joint Arthroplasty”.Acta Scientific Orthopaedics 6.4 (2023): 44-52.

Copyright

Copyright: © 2023 Gary Ulrich., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.