Updated: 6/12/2021

TKA Metal Hypersensitivity

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  • summary
    • TKA Metal Hypersensitivity is a complication of TKA that may lead to persistent knee pain and stiffness as a result of an allergic reaction to the metallic components.
    • Diagnosis involves careful patient history, and ruling out infection or aseptic loosening. Patch testing may be helpful in diagnosis.
    • Treatment generally involves component exchange to a hypoallergenic femoral component with all-polyethylene tibial component.
  • Epidemiology
    • Incidence
      • rare
  • Etiology
    • Pathophysiology
      • Type IV - delayed-type cell mediated hypersensitivity
        • mediated by T cells
      • reaction to
        • nickel found in cobalt-chromium alloys
        • metal ions deposit in local tissue, must react with proteins to initiate hypersensitivity
        • biggest link may be metal ions/hypersensitivity as a causative initiator of early implant loosening
  • Presentation
    • History
      • may have history of dermatitis, eczema, other signs of atopic hypersensitivity
    • Symptoms
      • vague persistent pain
      • persistent, unremitting effusion/swelling
      • stiffness
    • Physical exam
      • document range of motion
  • Studies
    • Evaluation
      • patch testing (limited evidence for direct link to diagnose hypersensitivity)
      • lymphocyte transformation test (LST)
      • T-lymphyocyte rich immunohistopathology
      • negative work-up for chronic/acute infection (must be ruled out)
    • Diagnosis
      • exact definition is controversial
        • some argue combination of a positive patch test, positive immunohistopathology, and relief of symptoms upon implant exchange is only way to confirm diagnosis
        • others argue that metal hypersensitivity is a diagnosis of exclusion, only arrived upon when infection and aseptic loosening is ruled out
  • Treatment
    • Operative
      • implant exchange
        • indications
          • persistent symptoms affecting quality of life
        • technique
          • hypoallergenic femoral component with all-polyethylene tibial component if possible
          • at time of surgery, chronic inflammatory synovitis typically present
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(SAE13BS.7) A 62-year-old woman has advanced osteoarthritis of the knee that has been refractory to nonsurgical treatment. She wishes to discuss total knee arthroplasty. She reports a lifelong history of intolerance to most jewelry and is concerned about having an allergic reaction to the metallic knee implant. Hypersensitivity to metal implants is usually classified as what type of Gell-Coombs reaction?

QID: 8308
1

I (allergic)

5%

(44/816)

2

II (cytotoxic, antibody-dependent)

2%

(19/816)

3

III (immune complex)

6%

(48/816)

4

IV (delayed type)

85%

(694/816)

L 1 D

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