Updated: 3/6/2017

TKA Metal Hypersensitivity

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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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