Updated: 3/6/2017

TKA Metal Hypersensitivity

Topic
Review Topic
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Questions
1
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Evidence
3
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Videos
1
Techniques
3
https://upload.orthobullets.com/topic/12753/images/soft_tissue_metal_allergy.jpg
Introduction
  • Incidence
    • rare
  • 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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Technique Guides (3)
Questions (1)

(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? Review Topic

QID: 8308
1

I (allergic)

5%

(20/397)

2

II (cytotoxic, antibody-dependent)

1%

(5/397)

3

III (immune complex)

5%

(19/397)

4

IV (delayed type)

87%

(344/397)

ML 1

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PREFERRED RESPONSE 4
ARTICLES (4)
VIDEOS (1)
Topic COMMENTS (2)
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