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Mortazavi SMJ, Antoci V, Hosseini-Monfared P, Razzaghof M, Tsiridis E, Tarabichi S, Tsai SW, Smailys A, Socorro NEM, Gavrankapetanovic I. Does Metal Allergy to Total Knee Arthroplasty Components Exist? J Arthroplasty 2025; 40:S113-S114. [PMID: 39454840 DOI: 10.1016/j.arth.2024.10.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2024] [Revised: 10/14/2024] [Accepted: 10/15/2024] [Indexed: 10/28/2024] Open
Affiliation(s)
| | - Valentin Antoci
- Division of Adult Reconstruction, Brown University, Warren Alpert Medical School, Providence, Rhode Island
| | | | - Mohammadreza Razzaghof
- Department of Orthopaedic Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Eleftherios Tsiridis
- President European Hip Society, President Hellenic Association of Orthopaedics & Trauma, Aristotle University Medical School, Thessaloniki, Greece
| | | | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, School of Medicine, National Yang Ming Chiao Tung University, Taipi, Taiwan
| | | | | | - Ismet Gavrankapetanovic
- Department of Surgery and War Surgery at the Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Chimento G, Daher J, Desai B, Velasco-Gonzalez C. Nickel allergy does not correlate with function after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2025; 33:646-653. [PMID: 39189133 DOI: 10.1002/ksa.12448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 08/28/2024]
Abstract
PURPOSE The purpose of this study is to determine if there is a relationship between clinical outcomes and nickel allergy by evaluating asymptomatic total knee arthroplasty (TKA) patients with well-functioning implants through quantitative metal allergy (MA) testing. METHODS A prospective case series was performed on 50 patients with well-functioning TKA of various implant types. Inclusion criteria included primary TKA with a minimum 12-month follow-up and Oxford knee score (OKS) ≥ 40. A commercially available Lymphocyte Transformation Test measured the amount of a hypersensitivity lymphocyte immune response after exposure to a particular antigen. MA results were stratified based on the stimulation index (SI). The Cochran-Mantel-Haenzel test was used to test the homogeneity of metal reactivities. The Wilcoxon-Mann-Whitney test was used to compare individual metal SI by gender and the association of OKS and metal SI was ascertained with the Spearman correlation. RESULTS Nickel, cobalt, and chromium do not have the same reactivity scores (p < 0.001), and only nickel showed reactive/highly reactive scores. Females were found to have 3.41 times the odds of males for higher Ni reactivity (p = 0.0295, odds ratio [OR], 95% confidence interval [CI] = 3.41 [1.13-10.3]) only. Clinically, there was no correlation between metal SI and OKS score by metal (Ni rho = -0.1779; Co rho = -0.0036; Cr rho = -0.1748). CONCLUSION This is the first study looking at MA in well-functioning TKA. There is no correlation between clinical results and nickel reactivity. Surgeons should exercise caution when revising a painful or poorly functioning TKA based solely on a 'positive' Nickel Allergy test and look for other possible reasons for failure. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- George Chimento
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Jimmy Daher
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Bhumit Desai
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Cruz Velasco-Gonzalez
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
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Emmert AS, Ruan T, Sherenian MG, Assa'ad AH, Leitsinger N, Schultz L, Jain VV, Sturm PF, Jones AC. Prevalence of metal hypersensitivity in pediatric spine surgery. Spine Deform 2025:10.1007/s43390-024-01030-7. [PMID: 39808266 DOI: 10.1007/s43390-024-01030-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Accepted: 12/19/2024] [Indexed: 01/16/2025]
Abstract
PURPOSE Delayed metal hypersensitivity reactions can cause complications in spine surgery. Currently, there is no information on the prevalence of metal hypersensitivity in pediatric patients undergoing spine surgery. The objective of this study is to determine the prevalence of metal hypersensitivity in pediatric patients undergoing spinal instrumentation. METHODS Retrospective chart review of patients who underwent spinal instrumentation with or without fusion at a single institution, from January 1, 2014, to December 31, 2020, was performed. Patients were pre-screened for history of allergic diseases, including previous reaction to metals, prior to surgery. Patch metal allergy testing (PMAT) for metal hypersensitivity was also performed. RESULTS Of the 796 pediatric patients who underwent spinal instrumentation procedures from 2014 to 2020, 118 (15%) screened positive for metal hypersensitivity. However, the number of patients with documented evidence of metal hypersensitivity diminished to 26 (3%) after PMAT verification. Nickel hypersensitivity was most prevalent, with 20 patients (16.9% of positive screening; 2.5% of all instrumented patients) demonstrating positive skin patch tests. The other most prevalent metal hypersensitivities included cobalt in 9 patients (7.6%; 1.1%), manganese in 3 patients (2.5%; 0.4%), and copper in 1 patient (0.8%; 0.1%). with a number needed to treat (NNT) of 5. CONCLUSIONS This study suggests that routine pre-operative PMAT is not necessary in all pediatric spine patients yet should be considered if patients report a history of prior metal hypersensitivity reactions.
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Affiliation(s)
- A Scott Emmert
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45242, USA
| | - Tiffany Ruan
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45242, USA
| | - Michael G Sherenian
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Amal H Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nichole Leitsinger
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45242, USA
| | - Lindsay Schultz
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45242, USA
| | - Viral V Jain
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45242, USA
| | - Peter F Sturm
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45242, USA
| | - Alvin C Jones
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45242, USA.
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Soler F, Murcia A, Benlloch M, Mariscal G. The impact of allergies on patient-reported outcomes after total hip and knee arthroplasty: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:3755-3765. [PMID: 39008079 DOI: 10.1007/s00402-024-05433-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/27/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Metal hypersensitivity has been associated with persistent symptoms after total hip arthroplasty (THA) and total knee arthroplasty (TKA), despite successful joint replacement. Allergies frequently co-occur and have been linked to psychiatric disturbances such as anxiety. There is a knowledge gap regarding the effect of allergies, including metal hypersensitivity, on patient-reported outcome measures (PROMs) after THA and TKA. This study aimed to evaluate the influence of allergies including metal hypersensitivity on PROMs in patients undergoing THA and TKA. MATERIAL AND METHODS A systematic search PROSPERO (CRD42023475972) was conducted using PubMed, EMBASE, Scopus, and Cochrane databases. Studies that compared allergic and non-allergic adults undergoing primary THA or TKA and reported PROMs were included. Methodological quality was assessed using the MINORS criteria. The mean differences (MD) and standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated. Eight studies, involving 33,808 patients, were included. RESULTS For functional outcomes assessed using SF-12, SF-36, KOOS JR, and HOOS JR, allergic patients demonstrated significantly worse scores (SMD - 0.23, 95% CI -0.36 to -0.09). The WOMAC functional scale also demonstrated poorer results in allergic patients (MD 2.49, 95% CI 0.64 4.35). For pain assessed using the WOMAC pain scale, allergic patients reported significantly greater pain (MD 1.04, 95% CI 0.46 1.62). Changes in mental status assessed using the SF-12 and SF-36 did not show significant differences between the groups (MD -0.46, 95% CI -1.40 to 0.47). In subgroup analysis, patients in the THA subgroup showed significantly worse outcomes (MD -7.20, 95% CI -12.97 - -1.43). CONCLUSION This meta-analysis found that patients with allergies, including metal hypersensitivity, generally had worse functional outcomes after THA and TKA than patients without allergies. Further research is required to confirm these findings. Preoperative allergy screening can identify individuals at risk of treatment optimization.
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Affiliation(s)
| | | | - María Benlloch
- Department of Basic Medical Sciences, Catholic University of Valencia, San Vicente Martir, Valencia San, Spain
| | - Gonzalo Mariscal
- Mediterranean Observatory for Clinical and Health Research, Carrer de Quevedo, 2, València, Valencia, 46001, Spain.
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Taliercio MJ, Alnabulsi RK, Uppal PA, Shaw IM, Semenza KM, Pasha MA. Metal implant allergy: A retrospective cohort analysis at a university allergy practice. Allergy Asthma Proc 2024; 45:186-194. [PMID: 38755777 DOI: 10.2500/aap.2024.45.240005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Background: Concern of metal sensitization in pre- and postsurgical evaluation is growing, with the recent guidelines remaining the criterion standard for consideration of patch testing. Information remains scarce on surgical screening in the groups of patients who reported a history of metal sensitivity versus those with no reported history. Objective: The objective of this study was to assess the utility of patch testing in surgical candidates based on reported metal allergy history. The secondary objective was to evaluate the utility and outcomes in postsurgical patch testing. Methods: Nine hundred and thirty-one patient charts of patients with the diagnosis of "contact dermatitis" who underwent an evaluation at a single allergy clinic site between January 2013 and December 2022 were identified and reviewed as part of a retrospective chart review study. Patients were included in subgroups based on the time of patch testing and history of reported metal allergy. Results: In all, 67 patients underwent patch testing, 10 (14.9%) of whom were surgical candidates without a history of metal sensitivity, 31 (46.2%) of whom were surgical candidates with a history of metal sensitivity, and 26 (38.8%) of whom were postsurgical patients. Twenty-nine (43.3%) of patients had positive patch testing results, with only one (10%) in the presurgical group, 17 (54.8%) in the presurgical with a history of metal sensitivity, and 11 (42.3%) in the postsurgical group. Zero patients in our cohort without metal sensitivity who were undergoing the Nuss procedure had positive reactions on patch testing, whereas two of four (50%) with reported metal sensitivity who were undergoing the Nuss procedure had positive relevant metal reactions. Conclusion: Ambiguity in the utility of patch testing for surgical decision making remains, despite common utilization. Recent guidelines along with coordination of care among the surgeon, allergist, and patient remains the criterion standard of care.
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Affiliation(s)
- Mark J Taliercio
- From the Department of Internal Medicine, Albany Medical Center, Albany, New York
| | - Rawaa K Alnabulsi
- Division of Allergy and Immunology, Department of Internal Medicine, Albany Medical Center, Albany, New York
| | | | - Ian M Shaw
- Department of Pediatrics, Albany Medical Collage, Albany, New York, and
| | - Kristy M Semenza
- Department of Allergy and Immunology, Bassett Medical Center, Cooperstown, New York
| | - Muhammad A Pasha
- Division of Allergy and Immunology, Department of Internal Medicine, Albany Medical Center, Albany, New York
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Chen A, Kurmis AP. Understanding immune-mediated cobalt/chromium allergy to orthopaedic implants: a meta-synthetic review. ARTHROPLASTY 2024; 6:1. [PMID: 38303027 PMCID: PMC10835847 DOI: 10.1186/s42836-023-00227-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/12/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND The frequency of primary joint replacement surgery continues to increase worldwide. While largely considered biologically inert entities, an increasing body of evidence continues to validate a not insignificant incidence of allergic reactions to such implants. Little previous work has explored genuinely immune-mediated reactivity in this context. In the absence of a contemporary published summary on the topic, this paper explored the current state of understanding of cobalt/chromium allergy and proposes a patient management algorithm whereby such immune reactions are clinically suggested. METHODS A structured, systematic literature review was performed by following PRISMA search principles to provide an updated review of this area. RESULTS Thirty-six topic-related articles were identified, the majority reflecting lower tiers of scientific evidence with a lack of homogeneous quantitative data to facilitate valid cohort comparisons. Largely, the available literature represented small case series' or expert opinions. CONCLUSIONS Despite increasing clinical awareness and acknowledgement of true allergy to joint replacement components, this review highlighted that the evidence base underpinning the diagnosis and management of such patients is limited. Both patient-reported metal allergy or skin patch testing are grossly unreliable methods and show almost no correlation with true immune reactivity. Recent studies suggested a potential role for patient-specific in vitro cellular activation testing and/or targeted genetic testing when cobalt/chromium allergy is clinically suspected. However, while likely representing the contemporary "best available" approaches both can be costly undertakings, are not yet universally available, and still require broader validation in non-research settings before wider uptake can be championed.
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Affiliation(s)
- Arnold Chen
- School of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Andrew P Kurmis
- Discipline of Medical Specialties, University of Adelaide, Adelaide, SA, 5000, Australia.
- Department of Orthopaedic Surgery, Lyell McEwin Hospital, Elizabeth Vale, SA, 5112, Australia.
- College of Medicine & Public Health, Flinders University, Bedford Park, SA, 5042, Australia.
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Migliorini F, Feierabend M, Hofmann UK. Fostering Excellence in Knee Arthroplasty: Developing Optimal Patient Care Pathways and Inspiring Knowledge Transfer of Advanced Surgical Techniques. J Healthc Leadersh 2023; 15:327-338. [PMID: 38020721 PMCID: PMC10676205 DOI: 10.2147/jhl.s383916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
Osteoarthritis of the knee is common. Early sports trauma or cartilage defects are risk factors for osteoarthritis. If conservative treatment fails, partial or total joint replacement is often performed. A joint replacement aims to restore physiological biomechanics and the quality of life of affected patients. Total knee arthroplasty is one of the most performed surgeries in musculoskeletal medicine. Several developments have taken place over the last decades that have truly altered the way we look at knee arthroplasty today. Some of the fascinating aspects will be presented and discussed in the present narrative review.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, 52074, Germany
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, 39100 Bolzano, Italy
| | - Martina Feierabend
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, 52074, Germany
| | - Ulf Krister Hofmann
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, 52074, Germany
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Shimmyo A, Takeda Y, Fukunishi S. Difficult Preoperative Diagnosis of Suspected Metal Hypersensitivity in a Case with Early Failure of Bipolar Hemiarthroplasty. Case Rep Orthop 2023; 2023:8656265. [PMID: 37292174 PMCID: PMC10247313 DOI: 10.1155/2023/8656265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/20/2023] [Accepted: 05/15/2023] [Indexed: 06/10/2023] Open
Abstract
Background Metal hypersensitivity is a rare complication after total hip arthroplasty (THA), and no reliable diagnostic method for metal hypersensitivity to orthopedic metal implants has yet been established. Case report. A 57-year-old woman underwent hemiarthroplasty using a metal implant despite a skin allergy to metal jewelry. Two years after surgery, the patient developed early hemiarthroplasty failure and refractory erythema. Although the patient was clinically suspected to have a hypersensitivity to metal, the preoperative screening test was negative, and patient underwent revision surgery with cemented THA. Postoperatively, the erythema as well as her hip pain disappeared completely. Conclusion Patients with clinically suspected metal hypersensitivity should undergo primary and revision total hip arthroplasty using hypoallergenic implants regardless of preoperative screening results.
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Affiliation(s)
- Airi Shimmyo
- Department of Orthopedic Surgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Yu Takeda
- Department of Orthopedic Surgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
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Filliquist B, McKay R, Marcellin-Little DJ, Irvin JJ, Garcia TC, Vernau W, Chou PY, Kapatkin AS, Vapniarsky N. Metal reactivity is present in dogs with tibial plateau leveling osteotomy and total hip replacement implants. Am J Vet Res 2023; 84:ajvr.22.08.0141. [PMID: 36652332 DOI: 10.2460/ajvr.22.08.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/25/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Determine whether dogs with well-functioning orthopedic metal implants can develop metal reactivity. SAMPLE Client-owned dogs that had tibial plateau leveling osteotomy (TPLO) or total hip replacement (THR) implants for 12 months or more and control dogs with no implants. PROCEDURES Lymphocyte transformation testing was performed by exposing peripheral blood lymphocytes to nickel (Ni), chromium (Cr), cobalt (Co), or a combination of these metals. Lymphocyte proliferation was assessed with flow cytometry. Lymphocyte stimulation indexes (SIs) were calculated. A SI > 2 was considered reactive. Median SIs of dogs in response to metal exposure were compared statistically. RESULTS Samples from 10 dogs with TPLO, 12 dogs with THR, and 7 control dogs were analyzed. Six dogs out of 22 with metal implants had a reactive SI to 1 or more metals, while 2 of 7 control dogs had a SI > 2 when exposed to nickel only. When all metals were considered, no differences in metal reactivity were found between TPLO, THR, and control groups. CLINICAL RELEVANCE Metal reactivity is present in dogs and can be identified using lymphocyte transformation testing. Reactivity to Ni is present in dogs with and without metal implants. Reactivity to Co and Cr occurs in some dogs with metal implants.
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Affiliation(s)
- Barbro Filliquist
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA.,JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Rachel McKay
- Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Denis J Marcellin-Little
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA.,JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Justine J Irvin
- JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Tanya C Garcia
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA.,JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - William Vernau
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Po-Yen Chou
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA.,JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Amy S Kapatkin
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA.,JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Natalia Vapniarsky
- JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA.,Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California-Davis, Davis, CA
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Schwartz BL, Pithadia DJ, Chen JK. Hypersensitivity to Implanted Metal Devices. CURRENT DERMATOLOGY REPORTS 2023. [DOI: 10.1007/s13671-023-00381-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Ganesan N, Ronsmans S, Hoet P. Methods to Assess Proliferation of Stimulated Human Lymphocytes In Vitro: A Narrative Review. Cells 2023; 12:cells12030386. [PMID: 36766728 PMCID: PMC9913443 DOI: 10.3390/cells12030386] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/10/2022] [Accepted: 01/18/2023] [Indexed: 01/24/2023] Open
Abstract
The ability to monitor lymphocyte responses is critical for developing our understanding of the immune response in humans. In the current clinical setting, relying on the metabolic incorporation of [3H] thymidine into cellular DNA via a lymphocyte proliferation test (LPT) is the only method that is routinely performed to determine cell proliferation. However, techniques that measure DNA synthesis with a radioactive material such as [3H] thymidine are intrinsically more sensitive to the different stages of the cell cycle, which could lead to over-analyses and the subsequent inaccurate interpretation of the information provided. With cell proliferation assays, the output should preferably provide a direct and accurate measurement of the number of actively dividing cells, regardless of the stimuli properties or length of exposure. In fact, an ideal technique should have the capacity to measure lymphocyte responses on both a quantitative level, i.e., cumulative magnitude of lymphoproliferative response, and a qualitative level, i.e., phenotypical and functional characterization of stimulated immune cells. There are many LPT alternatives currently available to measure various aspects of cell proliferation. Of the nine techniques discussed, we noted that the majority of these LPT alternatives measure lymphocyte proliferation using flow cytometry. Across some of these alternatives, the covalent labelling of cells with a high fluorescence intensity and low variance with minimal cell toxicity while maximizing the number of detectable cell divisions or magnitude of proliferation was achieved. Herein, we review the performance of these different LPT alternatives and address their compatibility with the [3H] thymidine LPT so as to identify the "best" alternative to the [3H] thymidine LPT.
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Affiliation(s)
- Nirosha Ganesan
- Laboratory of Toxicology, Unit of Environment & Health, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, 3000 Leuven, Belgium
| | - Steven Ronsmans
- Laboratory of Toxicology, Unit of Environment & Health, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
- Clinic for Occupational and Environmental Medicine, Department of Respiratory Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Peter Hoet
- Laboratory of Toxicology, Unit of Environment & Health, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, 3000 Leuven, Belgium
- Correspondence:
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Thienpont E. Titanium niobium nitride knee implants are not inferior to chrome cobalt components for primary total knee arthroplasty at medium-term follow-up. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04754-1. [PMID: 36595031 DOI: 10.1007/s00402-022-04754-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Oxidized zirconium (Oxinium), titanium nitride (TiN) or titanium niobium nitride (TiNbN) coated implants became in recent years available for an increasing amount of total knee arthroplasty (TKA) systems. The hypothesis of this study was that the use of TiNbN-coated components would not lead to inferior results compared to conventional implants and that none of the metal hypersensitivity patients receiving TiNbN-coated implants would require revision for metal allergy. MATERIALS AND METHODS This retrospective study compared 53 Titanium Niobium Nitride coated TKA with 103 conventional chrome cobalt implants of the same design. Patients were evaluated at a minimal follow-up of 3 years. RESULTS No differences in clinical, radiological or patient-reported outcome measurements were observed between these groups. A survivorship of 96% without differences in revision rates was observed at medium-term follow-up of 6.5 years. DISCUSSION Metal allergy leading to contact or generalized dermatitis after TKA is very rare and usually linked to chrome or cobalt hypersensitivity. Nickel release from knee implants has not been shown to lead to cutaneous symptoms, but unexplained pain and swelling, peri-prosthetic osteolysis and component loosening remain potential issues not fully understood. The use of coated implants eliminates this factor from the diagnostic equation in case of postoperative dissatisfaction. CONCLUSION The use of titanium niobium nitride coated implants for primary knee osteoarthritis in self-reported metal hypersensitivity patients shows similar outcomes and survivorship rates as conventional chrome cobalt TKA, with no revisions for allergy at medium-term follow-up.
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Affiliation(s)
- Emmanuel Thienpont
- Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
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Malahias MA, Bauer TW, Manolopoulos PP, Sculco PK, Westrich GH. Allergy Testing Has No Correlation with Intraoperative Histopathology from Revision Total Knee Arthroplasty for Implant-Related Metal Allergy. J Knee Surg 2023; 36:6-17. [PMID: 33932947 DOI: 10.1055/s-0041-1729618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Lymphocyte transformation testing (LTT) is often used in the workup for possible metal allergy after total knee arthroplasty (TKA) but the correlation of this test with other diagnostic metal-allergy findings in patients undergoing revision TKA for suspected metal allergy has not been established. A single-center, single-surgeon cohort of 19 TKAs in which both components were revised for presumed implant-related metal allergy based on history, physical, and LTT testing, to nonnickel-containing implants were retrospectively identified. Histopathologic samples obtained intraoperatively were semiquantitatively analyzed using both the Hospital for Special Surgery (HSS) synovial pathology score and the Campbell aseptic lymphocyte-dominant vasculitis-associated lesion (ALVAL) score. As histopathology control group, we included in the study an additional cohort of 17 patients who received aseptic revision TKA and had no history of reported or tested metal sensitivity. All preoperative LTT results were highly reactive to nickel. However, this did not correlate with local periarticular tissue response in 18 of 19 cases which demonstrated a low HSS synovial score (mean: 3.8 ± 2.8, of a maximum score of 28) and the low Campbell ALVAL scores (mean: 2.5/10 ± 1.3, of a maximum score of 10). There were not any significant differences between the study group (suspected implant-related metal allergy) and the control group (nonsuspected implant-related metal allergy) in regard to (1) the Campbell score and (2) the HSS synovial inflammatory score. Knee Society Clinical Rating System (KSCRS) function score improved significantly after revision (mean postoperative increase: 34.0 ± 17. 2; p < 0.001), as well as mean visual analog scale (VAS) pain (mean postoperative decrease: 33.3 ± 26.4; p < 0.01) score. The short-term survival rate (at mean follow-up of 26.1 months) of this patient cohort was 100%. In this cohort of revised TKA patients with suspected nickel allergy based on clinical presentation and LTT positive results, intraoperative histopathology was essentially normal. However, all patients with suspected nickel allergy showed a significant clinical and functional improvement with excellent short-term survival rates. The clinical significance of a positive LTT needs further study.
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Affiliation(s)
- Michael-Alexander Malahias
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, New York
| | - Thomas W Bauer
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, New York
| | - Philip P Manolopoulos
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, New York
| | - Peter K Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, New York
| | - Geoffrey H Westrich
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, New York
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14
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Bracey DN, Hegde V, Johnson R, Kleeman-Forsthuber L, Jennings J, Dennis D. Poor Correlation Among Metal Hypersensitivity Testing Modalities and Inferior Patient-Reported Outcomes After Primary and Revision Total Knee Arthroplasties. Arthroplast Today 2022; 18:138-142. [PMID: 36345325 PMCID: PMC9636001 DOI: 10.1016/j.artd.2022.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/16/2022] [Accepted: 09/22/2022] [Indexed: 11/06/2022] Open
Abstract
Background Metal allergy testing may influence clinical decision-making for patients undergoing a total knee arthroplasty (TKA). Limited data were found to examine the consistency of available testing modalities. This study compares different metal allergy test results and clinical outcomes after primary and revision TKAs in patients with and without metal hypersensitivity. Methods Primary (n = 28) and revision (n = 20) TKA patients receiving hypoallergenic implants for metal allergies diagnosed by skin patch testing (SPT), lymphocyte proliferation testing (LPT), or lymphocyte transformation testing (LTT) were retrospectively reviewed. The agreement between tests was assessed by percentage and kappa statistic within patients who used multiple testing modalities. Postoperative clinical outcomes of these patients were compared to those of patients without metal hypersensitivity matched by age (±5 years), body mass index (±5), gender, and follow-up duration (±2 years). Results SPT and LPT showed weak agreement for nickel and minimal agreement for cobalt. SPT and LTT showed minimal agreement for nickel; weak agreement for titanium, bone cement, vanadium, and zirconium; but strong agreement for chromium and cobalt. LPT and LTT agreement was weak. Compared to matched controls, metal hypersensitivity patients undergoing primary TKAs with hypoallergenic implants experienced less improvement in Knee Society Scores, Veterans RAND 12 physical component scores, and range of motion. Patients undergoing revision TKAs for multiple indications including metal hypersensitivity had worse clinical outcomes with significantly worse improvements in Knee Society functional scores compared to matched controls. Conclusions Metal allergy tests produce conflicting results. Hypersensitivity patients may experience inferior clinical outcomes even with hypoallergenic implants. Clinician awareness may influence the choice of testing and improve preoperative counseling of this patient population.
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Affiliation(s)
- Daniel N. Bracey
- Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Vishal Hegde
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Jason Jennings
- Colorado Joint Replacement, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
- Corresponding author. Colorado Joint Replacement Centre, 2535 S. Downing Street, Suite 100, Denver, CO 80210. Tel.: +1 720 524 1367.
| | - Douglas Dennis
- Colorado Joint Replacement, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
- Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO, USA
- Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
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15
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Peacock CJH, Fu H, Asopa V, Clement ND, Kader D, Sochart DH. The effect of Nickel hypersensitivity on the outcome of total knee arthroplasty and the value of skin patch testing: a systematic review. ARTHROPLASTY 2022; 4:40. [PMID: 36050799 PMCID: PMC9438335 DOI: 10.1186/s42836-022-00144-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To assess the Nickel sensitizing potential of total knee arthroplasty (TKA), explore the relationship between hypersensitivity and clinical outcomes, and evaluate the utility of skin patch testing pre- and/or postoperatively.
Materials and methods
A literature search was performed through EMBASE, Medline and PubMed databases. Articles were screened independently by two investigators. The level of evidence of studies was assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the quality evaluated using the Methodological Index for Non-randomized Studies and Cochrane risk-of-bias tools.
Results
Twenty studies met the eligibility criteria, reporting on 1354 knee arthroplasties. Studies included patients undergoing primary or revision TKA, pre- and/or postoperatively, and used patch testing to identify Nickel hypersensitivity. Prevalence of Nickel hypersensitivity ranged from 0% to 87.5%. One study compared the prevalence of Nickel hypersensitivity in the same patient group before and after surgery and noted newly positive patch test reactions in three patients (4.2%). Three studies reported lower prevalence of Nickel hypersensitivity in postoperative patients compared to preoperative ones. Seven studies suggested that hypersensitivity might cause adverse clinical outcomes, but six did not support any relationship. Seven studies recommended preoperative patch testing in patients with history of metal allergy, and nine concluded that testing may be valuable postoperatively.
Conclusions
Patients undergoing TKA with no prior history of metal hypersensitivity do not seem to be at an increased risk of developing Nickel hypersensitivity, and there is conflicting evidence that patients with pre-existing hypersensitivity are more likely to experience adverse outcomes. Patch testing remains the most commonly used method for diagnosing hypersensitivity, and evidence suggests preoperative testing in patients with history of metal allergy to aid prosthesis selection, and postoperatively in patients with suspected hypersensitivity once common causes of implant failure have been excluded, since revision with hypoallergenic implants may alleviate symptoms.
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16
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Impact of Preoperative Metal Patch Testing on Surgery Using Metal Implants. Arthroplast Today 2022; 14:170-174. [PMID: 35330665 PMCID: PMC8938599 DOI: 10.1016/j.artd.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 01/18/2022] [Accepted: 02/12/2022] [Indexed: 11/26/2022] Open
Abstract
Background Patients scheduled for metal implant surgery in some facilities in Japan undergo preoperative metal patch testing (MPT). However, few studies have reported the impact of MPT results on scheduled surgery; therefore, the value of preoperative MPT remains unknown. Material and methods In analysis 1,the preoperative MPT results requested by orthopedic surgeons from 4 institutions from 2014 to 2018 were retrospectively analyzed. In analysis 2, the medical records of all patients who underwent total hip arthroplasty, total knee arthroplasty, or total shoulder arthroplasty/reverse shoulder arthroplasty between 2014 and 2018 were collected. The number of patients who underwent MPT and their surgical results were analyzed. Results In analysis 1, MPT was performed on 72 patients during the study period. The overall MPT positivity rate was 26.4% for the entire cohort in analysis 1. In 4 out of 19 MPT-positive cases, the results of MPT changed the treatment plan to use alternative materials or cancel the surgery. In analysis 2, 1087 patients underwent total hip arthroplasty, total knee arthroplasty, and TSA/RSA; only 16 patients underwent MPT. Aseptic loosening occurred postoperatively in 3 patients (0.3%), none of whom had a history of allergy, and none underwent preoperative MPT. Conclusion Metal allergy did not appear to be directly involved in aseptic loosening to any large or meaningful degree in our patient cohort. Only 1.5% of the patients underwent preoperative MPT; therefore, our results suggest this testing had limited benefit or utility. Further studies are needed to determine whether MPT is necessary in preparation for joint replacement.
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Bogdanova-Bennett A, Sagi A, Asopa V, Field RE, Sochart DH. Nickel hypersensitivity and skin patch testing in total hip replacement surgery: a systematic review. EFORT Open Rev 2021; 6:825-838. [PMID: 34760283 PMCID: PMC8559563 DOI: 10.1302/2058-5241.6.210051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Approximately 60,000 cemented femoral stems are implanted in the UK each year with the majority being manufactured from stainless steel containing 10–15% nickel. Nickel hypersensitivity has been reported in up to 13% of the general population and there is a concern that nickel hypersensitivity might adversely affect the outcome of total hip replacement (THR). We reviewed the current literature on the potential link between nickel hypersensitivity and THR complications, and the usefulness of patch testing. We conducted a literature search in PubMed, MEDLINE and EMBASE databases. The level of evidence and the quality of the selected studies were assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the Methodological Index for Non-Randomised Studies tool, respectively. Twenty-six studies met the inclusion criteria, reporting on 1852 patients who underwent primary or revision THR. All studies detailed skin patch testing and recorded prevalence of nickel hypersensitivity from 1.5% to 33.3%. Five studies reported a rise in Nickel hypersensitivity following THR, while four reported a decreased prevalence post-operatively. Eight studies concluded that metal hypersensitivity could have developed following THR, while seven studies did not support a link between metal hypersensitivity and THR complications. Four of the studies recommended routine patch testing pre-operatively, but three others concluded that routine patch testing was not indicated. We have not identified a link between nickel hypersensitivity and THR complications, and the role of patch testing remains unclear. Further large-scale studies would be required to investigate this relationship and to clarify the role of patch testing in facilitating implant selection. Cite this article: EFORT Open Rev 2021;6:825-838. DOI: 10.1302/2058-5241.6.210051
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Affiliation(s)
| | - Amit Sagi
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
| | - Vipin Asopa
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
| | - Richard E Field
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
| | - David H Sochart
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
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No Clinical or Radiographic Differences Between Cemented Cobalt-Chromium and Titanium-Niobium Nitride Mobile-Bearing Unicompartmental Knee Arthroplasty. Indian J Orthop 2021; 55:1195-1201. [PMID: 34824720 PMCID: PMC8586226 DOI: 10.1007/s43465-021-00486-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/10/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to compare the clinical and radiographic outcomes of patients with positive patch tests undergoing a medial mobile-bearing titanium-niobium nitride (TiNbN) unicompartmental knee arthroplasty (UKA) to patients undergoing standard UKA (cobalt-chromium [CoCr] implants). METHODS Two successive groups of patients, amounting to a total of 246 individuals, who received Oxford (Zimmer-Biomet, Warsaw, Indiana, USA) UKA were included. The first group was composed of a series of 203 consecutive standard CoCr UKAs (Standard Group), while the second group comprised 43 consecutive hypoallergenic TiNbN UKAs (HA group). The patients of the second group had a positive epicutaneous patch test result for metals. Each patient was evaluated using the Oxford Knee Score (OKS) and Knee Society Score (KSS) a day prior to the surgery (T 0) and at two consecutive follow-ups, namely T 1 (minimum follow-up of 12 months) and T 2 (minimum follow-up of 34 months). Radiographic measurements were performed at the final follow-up (T 2). RESULTS No statistical differences were noted between the two groups regarding demographic data (p > 0.05). No clinical or radiographic differences were found between the HA and standard groups at any follow-up (p > 0.05). A statistically significant improvement was found at any follow-up for both OKS and KSS (p < 0.05). CONCLUSIONS No clinical or radiographic differences between the hypoallergenic and standard cobalt-chromium groups at any follow-up were found, with a clinically significant improvement being experienced by both groups during the entire follow-up. LEVEL OF EVIDENCE Level II-comparative prospective study. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00486-3.
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Titanium and Other Metal Hypersensitivity Diagnosed by MELISA® Test: Follow-Up Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5512091. [PMID: 34124241 PMCID: PMC8192180 DOI: 10.1155/2021/5512091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/07/2021] [Accepted: 05/20/2021] [Indexed: 11/22/2022]
Abstract
This study is aimed at proving the clinical benefit of the MELISA® test in the minimization or complete elimination of health problems in patients with confirmed hypersensitivity to metals used for tissue replacements. A group of 305 patients aged 20-75 years with previously proven metal hypersensitivity (initial MELISA® test), mainly to titanium and then to another fifteen metals, was chosen from the database at the Institute of Dental Medicine. From these patients, a final group of 42 patients agreed to participate in the study, 35 of which were female and 7 were male. The patients completed a special questionnaire aimed at information regarding change of health status from their last visit and determining whether the results of the initial MELISA® test and recommendations based on it were beneficial for patients or not. They were clinically examined, and peripheral blood samples were taken to perform follow-up MELISA® tests. Questionnaire data was processed, and the follow-up MELISA® test results were compared with the results of the initial MELISA® tests. For statistical analysis, the Fisher's exact test and paired T-test were used. Thirty-two patients reported that they followed the recommendations based on the results of the initial MELISA® tests, and of these, 30 patients (94%) confirmed significant health improvement. Six patients did not follow the recommendation, and from these, only one patient reported an improvement in his health problems. By comparison of the initial and follow-up MELISA® test results, it can be stated that the hypersensitivity to the given metal decreased or disappeared after the therapeutic interventions performed based on the initial MELISA® test results. The evaluation of the data obtained from patients in this study confirmed a significant clinical benefit of MELISA® test.
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20
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Avila JD, Bandyopadhyay A. Zirconia-Toughened Alumina Coated Ti6Al4V via Additive Manufacturing. MATERIALS LETTERS 2021; 291:129577. [PMID: 33692601 PMCID: PMC7939135 DOI: 10.1016/j.matlet.2021.129577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
CoCr alloy-based femoral heads have failed prematurely due to galvanic-induced corrosion when coupled with a titanium hip stem. Coupling a titanium based-femoral head with the titanium hip stem is ideal in addressing this failure mode. Ti6Al4V (Ti64) alloy was reinforced with zirconia-toughened alumina (ZTA) by directed-energy deposition (DED)-based additive manufacturing (AM) to address that concern. Preliminary materials processing work resulted in failed samples due to cracking, porosity, and delamination. After careful parameter optimization, a Ti64+5wt.%ZTA (5ZTA) composition produced a metallurgically sound and coherent interface, minimal porosity, and bulk structures. Hardness was observed to increase by 27%, normalized wear rate reduced by 25%, and contact resistance increased during in vitro tribological testing along with faster surface re-passivation.
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21
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Metal Hypersensitivity in Joint Arthroplasty. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202103000-00007. [PMID: 33720103 PMCID: PMC7963506 DOI: 10.5435/jaaosglobal-d-20-00200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/31/2021] [Indexed: 11/18/2022]
Abstract
Metal hypersensitivity in joint arthroplasty is a very controversial topic with limited evidence. With increasing numbers of joint replacements being done annually, a clear understanding of the pathogenesis, clinical picture, preimplant screening, postimplant workup, and treatment plan is crucial. This review article looked at all the available evidence regarding metal hypersensitivity and summarized the key findings. An algorithm was also proposed for preimplant screening, postimplant workup, and management.
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22
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Law JI, Morris MJ, Hurst JM, Berend KR, Lombardi AV, Crawford DA. Early Outcomes of an Alternative Bearing Surface in Primary Total Knee Arthroplasty in Patients with Self-reported Metal Allergy. Arthroplast Today 2020; 6:639-643. [PMID: 32875011 PMCID: PMC7451939 DOI: 10.1016/j.artd.2020.07.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/25/2020] [Accepted: 07/10/2020] [Indexed: 01/27/2023] Open
Abstract
Background Most implants for total knee arthroplasty (TKA) are comprised of alloys that contain nickel. Controversy exists whether metal allergies produce negative effects and affect clinical outcomes. The purpose of this study was to retrospectively review a minimum 2-year follow-up with an ion-bombarded titanium TKA implant in patients with reported metal sensitivity. Methods A retrospective review of patients who underwent primary TKA with the ion-bombarded titanium Vanguard (Zimmer Biomet, Warsaw, IN) implant with 2-year minimum follow-up was performed from 2008 through 2017. The query revealed 346 patients (451 knees) with minimum 2-year follow-up. The mean age was 64.7 years, the mean body mass index was 35.1 kg/m2, and 95% of patients were women. Results The mean follow-up was 4.6 years. The mean range of motion improved from 109° to 112° (P = .03), University of California Los Angeles activity scale from 4.1 to 5.1 (P < .001), Knee Society Clinical scores from 36 to 89 (P < .001), and Knee Society Functional scores from 48 to 73 (P < .001). There were 5 (1.1%) revisions: 2 infections (2-staged exchange), 1 tibial revision for aseptic loosening after a fall, and 2 bearing exchanges for instability. Other surgeries were open reduction internal fixation of periprosthetic fracture, 1 arthroscopic release of snapping popliteus, and 4 local wound incision and debridement (2 superficial infections and 2 nonhealing wounds). Manipulation under anesthesia was required in 27 (6%) patients. Conclusions These early results are encouraging for the use of alternative metal titanium alloy implants in metal-sensitive patients undergoing primary TKA. At 4.6 years of mean follow-up, patients had substantial improvement in the range of motion and clinical outcomes with a low frequency of revision.
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Affiliation(s)
- Jesua I Law
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
| | - Micael J Morris
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
| | - Jason M Hurst
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
| | - Keith R Berend
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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23
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Charousset C, Lefebvre Y, Bonnevialle N, Joudet T, Audebert S, Berhouet J, Michelet A, Geais L, Godenèche A. Prevalence of metal hypersensitivity in patients with shoulder pathologies. J Shoulder Elbow Surg 2020; 29:1789-1795. [PMID: 32371039 DOI: 10.1016/j.jse.2020.01.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/22/2020] [Accepted: 01/28/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND To date, medical history and dedicated questionnaires are the fastest and easiest way to assess risks of joint metal hypersensitivity. No published studies determined the overall prevalence of hypersensitivity to metals in patients with shoulder pathologies. The purpose of this study was therefore to estimate the prevalence of metal hypersensitivity reported by patients with shoulder pathologies, and to identify patients at risk of joint metal hypersensitivity based on a dedicated questionnaire. METHODS The authors prospectively asked all adult patients consulting for shoulder pathologies between September 2018 and February 2019 at 10 centers to fill in a form. The main outcome was "reported hypersensitivity to metals," comprising belt buckles, coins, earrings, fancy jewelry, keys, leather, metallic buttons, piercings, spectacles, watch bracelets, or zips. RESULTS A total of 3217 patients agreed to fill in the survey, aged 55 ± 16 (range, 18-101) with equal proportions of men (51%) and women (49%), and a majority of patients consulting for cuff pathology (55%). A total of 891 (28%) patients had professions considered at risk for metal hypersensitivity. The most frequently reported metal hypersensitivities were fancy jewelry (15%), earrings (13%), and watch bracelets (9%). A total of 629 (20%) patients, of which the vast majority were women, reported hypersensitivity to 1 or more metals. CONCLUSIONS This survey of 3217 patients identified 20% who reported metal hypersensitivities, though only 2.2% had done patch tests. Matching profiles of those with positive patch tests to those with no patch tests revealed that 9.4% of the total cohort had similar sex and self-reported metal hypersensitivities. Factors associated with a positive patch test were female sex, self-reported cutaneous allergy, and self-reported metal hypersensitivity. The clinical applicability of these estimates remains uncertain as there is insufficient evidence that allergy to metal implants can be predicted by questionnaires or patch tests.
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Affiliation(s)
| | - Yves Lefebvre
- Institut de l'Epaule de Strasbourg 16, allée de la Robertsau, Strasbourg, France
| | - Nicolas Bonnevialle
- Département de chirurgie orthopédique, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Thierry Joudet
- Department of Orthopaedic Surgery, Clinique chirurgicale du Libournais, Libourne, France
| | - Stephane Audebert
- Department of Orthopaedic Surgery, Clinique du Cambresis, Cambrai, France
| | - Julien Berhouet
- Service d'Orthopédie 1C, Centre Hospitalier Universitaire de Tours, Tours, France
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- Shoulder Friends Institute, Paris, France
| | | | | | - Arnaud Godenèche
- Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
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Bjørklund G, Dadar M, Chirumbolo S, Aaseth J, Peana M. Metals, autoimmunity, and neuroendocrinology: Is there a connection? ENVIRONMENTAL RESEARCH 2020; 187:109541. [PMID: 32445945 DOI: 10.1016/j.envres.2020.109541] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/04/2020] [Accepted: 04/14/2020] [Indexed: 06/11/2023]
Abstract
It has been demonstrated that metals can induce autoimmunity. However, few studies have attempted to assess and elucidate the underlying mechanisms of action. Recent research has tried to evaluate the possible interactions of the immune system with metal ions, particularly with heavy metals. Research indicates that metals have the potential to induce or promote the development of autoimmunity in humans. Metal-induced inflammation may dysregulate the hypothalamic-pituitary-adrenal (HPA) axis and thus contribute to fatigue and other non-specific symptoms characterizing disorders related to autoimmune diseases. The toxic effects of several metals are also mediated through free radical formation, cell membrane disturbance, or enzyme inhibition. There are worldwide increases in environmental metal pollution. It is therefore critical that studies on the role of metals in autoimmunity, and neuroendocrine disorders, including effects on the developing immune system and brain and the genetic susceptibility are performed. These studies can lead to efficient preventive strategies and improved therapeutic approaches. In this review, we have retrieved and commented on studies that evaluated the effects of metal toxicity on immune and endocrine-related pathways. This review aims to increase awareness of metals as factors in the onset and progression of autoimmune and neuroendocrine disorders.
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Affiliation(s)
- Geir Bjørklund
- Council for Nutritional and Environmental Medicine, Mo i Rana, Norway.
| | - Maryam Dadar
- Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization (AREEO), Karaj, Iran
| | - Salvatore Chirumbolo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; CONEM Scientific Secretary, Verona, Italy
| | - Jan Aaseth
- Research Department, Innlandet Hospital Trust, Brumunddal, Norway; IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Massimiliano Peana
- Department of Chemistry and Pharmacy, University of Sassari, Sassari, Italy
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Takaoka Y, Goto K, Kuroda Y, Kawai T, Matsuda S. The Long-Term Results of Total Hip Arthroplasty With a Cemented β-Titanium Stem. J Arthroplasty 2020; 35:2167-2172. [PMID: 32359958 DOI: 10.1016/j.arth.2020.03.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/20/2020] [Accepted: 03/28/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We report on the outcomes of a double-tapered cemented stem made of β-titanium alloys (Ti-15Mo-5Zr-3Al) at least 10 years after total hip arthroplasty. METHODS We retrospectively analyzed 148 consecutive, primary total hip arthroplasties using this stem performed in 130 patients between January 2004 and August 2008. The patients' mean age was 59.6 years (range, 24-79). Implant survival was evaluated using Kaplan-Meier curves with the primary end point being stem revision for any reason and the secondary end point being stem revision for aseptic stem loosening. We also clinically and radiologically followed 140 hips (in 123 patients) for an average of 12.2 years (range, 10-15). RESULTS The only revisions were for 2 stems with deep infection. Ten-year survival was 99.3% (95% confidence interval, 95.4%-99.9%) and 100% for the primary and secondary end point, respectively. The mean Japanese Orthopaedic Association hip score improved from 51.4 preoperatively to 88.7 at the last follow-up. Radiolucent lines at the stem-cement interface were seen in 14 hips (10.0%). None of the hips met the criteria of radiological stem loosening. Nineteen stems (13.6%) subsided by around 1 mm between 2 and 8 years after surgery. Distal femoral cortical hypertrophy occurred in 24 hips (17.0%), mostly with valgus alignment. CONCLUSION The clinical outcomes of the femoral stems were excellent with survival at 10 years. Stem subsidence and distal femoral cortical hypertrophy did not affect the results. Long-term use of β-titanium alloy stems is safe and effective.
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Affiliation(s)
- Yusuke Takaoka
- Department of Orthopaedic surgery, Kyoto University Hospital, Sakyo-Ku, Japan
| | - Koji Goto
- Department of Orthopaedic surgery, Kyoto University Hospital, Sakyo-Ku, Japan
| | - Yutaka Kuroda
- Department of Orthopaedic surgery, Kyoto University Hospital, Sakyo-Ku, Japan
| | - Toshiyuki Kawai
- Department of Orthopaedic surgery, Kyoto University Hospital, Sakyo-Ku, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic surgery, Kyoto University Hospital, Sakyo-Ku, Japan
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Hassan S, Mercuri LG, Miloro M. Does Metal Hypersensitivity Have Relevance in Patients Undergoing TMJ Prosthetic Replacement? J Oral Maxillofac Surg 2020; 78:908-915. [DOI: 10.1016/j.joms.2020.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 01/14/2020] [Indexed: 02/07/2023]
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Kennon JC, Lee J, Songy C, Shukla D, Cofield RH, Sanchez-Sotelo J, Sperling JW. The effect of patient-reported metal allergies on the outcomes of shoulder arthroplasty. J Shoulder Elbow Surg 2020; 29:296-301. [PMID: 31427231 DOI: 10.1016/j.jse.2019.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/29/2019] [Accepted: 06/07/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although literature exists regarding hip and knee arthroplasty outcomes in patients with skin allergy to metals, there is minimal information about skin allergy implications on shoulder arthroplasty outcomes. The purpose of this study was to determine the results, complications, and failure rate among patients with a self-reported metal allergy undergoing shoulder arthroplasty. METHODS Fifty-two shoulder arthroplasties were performed at our Institution in 43 patients with self-reported metal allergies. Forty primary and 12 revision shoulder arthroplasties were performed using anatomic (30) and reverse (22) components. Retrospective chart review was performed to determine metal allergy history, implant composition, pain, motion, and complications. Radiographs were reviewed to determine mechanical failure rates. Average follow-up time was 65 months. RESULTS Allergies reported included nickel (37), cobalt chrome (4), copper (2), zinc (1), titanium (1), gold (1), and nonspecific metal allergy (8); 8 patients reported multiple metal allergies. All components implanted in patients with nickel allergies contained nickel. At most recent follow-up, pain was rated as none or mild in 88% of shoulders. Active elevation improved from 80° to 141° and external rotation from 24° to 52°. Two revisions were performed for glenoid loosening (3.8%); both were revision cases with substantial glenoid bone loss. One patient with mild pain had a radiographically loose glenoid component 12 years after anatomic shoulder arthroplasty. CONCLUSION Results from this study suggest that shoulder arthroplasty in patients with self-reported metal allergy provides satisfactory pain relief and improved range of motion with low revision rates.
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Affiliation(s)
- Justin C Kennon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Julia Lee
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Chad Songy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dave Shukla
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Robert H Cofield
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - John W Sperling
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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Kumar S, Nehra M, Kedia D, Dilbaghi N, Tankeshwar K, Kim KH. Nanotechnology-based biomaterials for orthopaedic applications: Recent advances and future prospects. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 106:110154. [DOI: 10.1016/j.msec.2019.110154] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/04/2019] [Accepted: 08/31/2019] [Indexed: 12/13/2022]
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Abstract
Allergic contact dermatitis is common, resulting in considerable morbidity. Diagnosis is based on a thorough history, physical examination, and patch testing. Several commercially available panels of patch testing are currently used. Allergens are found in a wide variety of daily products, occupational exposures, and foods. The mainstay of treatment is avoidance of the allergen, and databases like Contact Allergen Management Program and Contact Allergen Replacement Database help patients to select products that do not contain allergens to which they are sensitized. Topical corticosteroids can be used to treat exacerbations, but should be avoided in long-term treatment.
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Affiliation(s)
- Stacy Nassau
- Department of Internal Medicine, Section of Allergy and Immunology, NYU Winthrop University Hospital, 120 Mineola Boulevard, Suite 410, Mineola, NY 11501, USA.
| | - Luz Fonacier
- Department of Internal Medicine, Section of Allergy and Immunology, NYU Winthrop University Hospital, 120 Mineola Boulevard, Suite 410, Mineola, NY 11501, USA
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Abstract
There are very few reports of eczema and other prosthetic-related allergic skin complications following arthroplasty. We aimed to assess the risk of eczema after joint replacement.We performed a retrospective population-based cohort study in 2024 joint replacement patients using the Longitudinal Health Insurance Database. For comparison, 8096 controls were selected, with 4 control subjects for each joint replacement patient matched for age, sex, and index year, to assess eczema risk. We examined 14-year cumulative eczema incidence associated with age, sex, immunity, disease history, and joint replacement location.Eczema rates in the joint replacement patients were 38% higher than in the control group (57.90 vs 41.84 per 1000 person-years, respectively). Compared with the control group, joint replacement patients showed a 1.35-fold increased risk of eczema according to the multivariable Cox model (95% Confidence interval [CI] = 1.23-1.49). Knee replacement patients had higher eczema risk compared with the control group (Hazard ratio [HR] = 1.45, 95% CI = 1.33-1.70). Stratified by study period, the joint replacement cohort had a higher eczema risk after the 3-month follow-up.Our study revealed that joint arthroplasty increased risk of eczema in this 14-year follow-up study, and this was not related to personal atopic history or gender.
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Affiliation(s)
- Po-Yuan Wu
- Department of Dermatology, China Medical University Hospital
- School of Medicine, China Medical University
| | | | - Chun-Hao Tsai
- School of Medicine, China Medical University
- Department of Orthopedics, China Medical University Hospital
- Department of Sports Medicine/School of Medicine, China Medical University, Taichung, Taiwan
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Schmidt KJ, Huang PS, Colwell CW, McCauley JC, Pulido PA, Bugbee WD. Self-Reported Metal Allergy and Early Outcomes After Total Knee Arthroplasty. Orthopedics 2019; 42:330-334. [PMID: 31505017 DOI: 10.3928/01477447-20190906-01] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 11/26/2018] [Indexed: 02/03/2023]
Abstract
The impact of self-reported metal allergy (SRMA) in total knee arthroplasty (TKA) remains controversial. In the absence of objective tests, SRMA is often used as a screening tool for implant selection. The objective of this study was to determine the effect of SRMA on early outcomes after TKA. Between 2010 and 2014, 168 patients with SRMA underwent TKA; 150 (89%) received nickel-free implants, and 18 (11%) received cobalt-chrome implants that contained nickel. Mean age was 67 years, and 95% were female. A cohort of 858 TKA patients (mean age, 68 years) without SRMA matched by sex served as the control group. Outcomes included Knee Society Score (function [KSS-F] and knee [KSS-K]), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, knee flexion, further surgery, and complications. No differences were seen in KSS-F and KSS-K between patients with and without SRMA. The mean WOMAC pain scores were 89.1 for patients with SRMA and 85.2 for patients without SRMA (P=.030). Stiffness and physical function scores were similar. Knee flexion was similar. No differences were found between nickel-free and cobalt-chrome SRMA groups. Patients with SRMA and those without demonstrated similar early functional outcomes. Patients with SRMA who received standard cobalt-chrome implants had no significant difference in functional outcomes compared with patients with nickel-free implants. Better identifiers of patients at risk for adverse events due to implant material are needed. [Orthopedics. 2019; 42(6):330-334.].
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Richards LJ, Streifel A, Rodrigues JM. Utility of Patch Testing and Lymphocyte Transformation Testing in the Evaluation of Metal Allergy in Patients with Orthopedic Implants. Cureus 2019; 11:e5761. [PMID: 31723520 PMCID: PMC6825456 DOI: 10.7759/cureus.5761] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Total joint arthroplasties are increasingly common orthopedic procedures performed throughout the United States. Implant failure after these procedures occurs due to a number of causes such as infection or mechanical problems, with metal hypersensitivity being an area of growing interest. The nature and mechanism of a causative relationship between metal hypersensitivity and implant failure have been unclear as it is not known whether implant failure occurs due to a previous metal allergy or metal allergy results from secondary sensitization via metal exposure in existing failing implants. Overall, there appears to be growing support and evidence for metal-hypersensitive patients having worse outcomes with regard to total hip and knee arthroplasties. However, there are conflicting recommendations (outside of Nuss procedures) for pre-implant testing for metal hypersensitivity as testing has not consistently been shown to change patient outcomes.
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Affiliation(s)
- Logan J Richards
- Miscellaneous, University of North Dakota School of Medicine and Health Sciences, Bismarck, USA
| | - Alexandra Streifel
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Bismarck, USA
| | - Jonathan M Rodrigues
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Bismarck, USA
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Christiansen RJ, Münch HJ, Bonefeld CM, Thyssen JP, Sloth JJ, Geisler C, Søballe K, Jellesen MS, Jakobsen SS. Cytokine Profile in Patients with Aseptic Loosening of Total Hip Replacements and Its Relation to Metal Release and Metal Allergy. J Clin Med 2019; 8:jcm8081259. [PMID: 31434199 PMCID: PMC6723430 DOI: 10.3390/jcm8081259] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/06/2019] [Accepted: 08/09/2019] [Indexed: 12/13/2022] Open
Abstract
Metal release from total hip replacements (THRs) is associated with aseptic loosening (AL). It has been proposed that the underlying immunological response is caused by a delayed type IV hypersensitivity-like reaction to metals, i.e., metal allergy. The purpose of this study was to investigate the immunological response in patients with AL in relation to metal release and the prevalence of metal allergy. THR patients undergoing revision surgery due to AL or mechanical implant failures were included in the study along with a control group consisting of primary THR patients. Comprehensive cytokine analyses were performed on serum and periimplant tissue samples along with metal analysis using inductive coupled plasma mass spectrometry (ICP-MS). Patient patch testing was done with a series of metals related to orthopedic implant. A distinct cytokine profile was found in the periimplant tissue of patients with AL. Significantly increased levels of the proinflammatory cytokines IL-1β, IL-2, IL-8, IFN-γ and TNF-α, but also the anti-inflammatory IL-10 were detected. A general increase of metal concentrations in the periimplant tissue was observed in both revision groups, while Cr was significantly increased in patient serum with AL. No difference in the prevalence of metal sensitivity was established by patch testing. Increased levels of IL-1β, IL-8, and TNF-α point to an innate immune response. However, the presence of IL-2 and IFN-γ indicates additional involvement of T cell-mediated response in patients with AL, although this could not be detected by patch testing.
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Affiliation(s)
- Rune J Christiansen
- Department of Mechanical Engineering, Technical University of Denmark, DK-2800 Kgs. Lyngby, Denmark.
- Department of Immunology and Microbiology, University of Copenhagen, DK-2200 Copenhagen, Denmark.
| | - Henrik J Münch
- Institute of Clinical Medicine-Orthopedic Surgery, Aarhus University, DK-8000 Aarhus C, Denmark
| | - Charlotte M Bonefeld
- Department of Immunology and Microbiology, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Jacob P Thyssen
- Institute of Clinical Medicine, Copenhagen University, Gentofte Hospital, DK-2900 Hellerup, Denmark
| | - Jens J Sloth
- National Food Institute, Research Group on Nanobio Science, Technical University of Denmark, DK-2860 Søborg, Denmark
| | - Carsten Geisler
- Department of Immunology and Microbiology, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Kjeld Søballe
- Institute of Clinical Medicine-Orthopedic Surgery, Aarhus University, DK-8000 Aarhus C, Denmark
| | - Morten S Jellesen
- Department of Mechanical Engineering, Technical University of Denmark, DK-2800 Kgs. Lyngby, Denmark
| | - Stig S Jakobsen
- Institute of Clinical Medicine-Orthopedic Surgery, Aarhus University, DK-8000 Aarhus C, Denmark.
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Kovochich M, Finley BL, Novick R, Monnot AD, Donovan E, Unice KM, Fung ES, Fung D, Paustenbach DJ. Understanding outcomes and toxicological aspects of second generation metal-on-metal hip implants: a state-of-the-art review. Crit Rev Toxicol 2019; 48:853-901. [DOI: 10.1080/10408444.2018.1563048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Santy-Tomlinson J, Jomeen J, Ersser SJ. Patient-reported symptoms of 'calm', 'irritated' and 'infected' skeletal external fixator pin site wound states; a cross-sectional study. Int J Orthop Trauma Nurs 2019; 33:44-51. [PMID: 30885643 DOI: 10.1016/j.ijotn.2019.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/12/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To explore the frequency, severity and variances in patient-reported symptoms of calm, irritated and infected skeletal pin sites. METHODS A cross-sectional within-subjects repeated-measures study was conducted, employing a self-report questionnaire. Patients (n = 165) treated with lower limb external fixators at 7 English hospitals completed a designed questionnaire. Three sets of retrospective repeated-measures data were collected relating to calm, irritated and infected pin sites. RESULTS Significant differences were revealed between each of the three pin site states (calm, irritated & infected) in the degree of: redness, swelling, itchiness, pain, wound discharge, heat/burning, shiny skin and odour. In relation to difficulty or pain using the affected arm or leg, difficulty weight bearing on the leg, nausea and/or vomiting, feeling unwell or feverish, shivering, tiredness/lethargy and disturbed sleep, significant differences were demonstrated between infected and irritated states and infected and calm states, but not between irritated and calm. CONCLUSIONS The findings provide greater depth of understanding of the symptoms of pin site infection and irritation. Patients may be able to differentiate between different pin site states by comparing the magnitude of the inflammatory symptoms and the presence of other specific symptoms that relate solely to infection and no other clinical state. The irritated state is probably caused by a different pathological processother than infection and may be an indication of contact dermatitis.
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Affiliation(s)
- Julie Santy-Tomlinson
- Orthopaedic Department, Odense University Hospitals & University of Southern Denmark, Denmark.
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Xiang S, Zhao Y, Li Z, Feng B, Weng X. Clinical outcomes of ceramic femoral prosthesis in total knee arthroplasty: a systematic review. J Orthop Surg Res 2019; 14:57. [PMID: 30782186 PMCID: PMC6381750 DOI: 10.1186/s13018-019-1090-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 02/05/2019] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Ceramic bearings have been widely used in total hip arthroplasty (THA), which resulted in satisfactory clinical outcomes due to the excellent tribological characteristics of the implants. However, ceramic components are not commonly used in total knee arthroplasty (TKA) because of brittleness. This study aimed to gather and analyze information regarding the clinical outcomes (including survival without revision, causes of revision, functional outcome, and incidence of loosening) and reach a definitive conclusion about the use of ceramic femoral components in total knee arthroplasty. METHODS MEDLINE, EMBASE, Cochrane, and ClinicalTrials.gov databases were searched for studies that reported the clinical and/or radiological outcomes with or without survival data of ceramic TKA implants and that included more than 10 patients with a minimum of 1 year follow-up. RESULTS From an initial sample of 147, there were 14 studies that met the inclusion criteria. Overall, there was a notable enhancement of joint function after the procedure, with a satisfactory mid- and long-term survival of the ceramic components, which is comparable to that of the conventional alloy components reported previously. In addition, the revision rate was reported to be between 0% and 14.37% according to the included studies. However, revision due to aseptic loosening, wear, and component fracture appeared to be rare, demonstrating the safety of in vivo use of ceramic bearings in the TKA procedure. CONCLUSIONS Ceramic TKA implants show similar post-operative clinical results and survival rate compared to their conventional metallic counterparts. Our results confirmed the safety of in vivo use of ceramic bearings in TKA, with rare implant breakage and aseptic loosening. Considering the excellent characteristics of the tribology of ceramics, the clinical use of ceramic prostheses in TKA could be promising.
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Affiliation(s)
- Shuai Xiang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, 100730, China
| | - Yan Zhao
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, 100730, China
| | - Zeng Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, 100730, China
| | - Bin Feng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, 100730, China
| | - Xisheng Weng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, 100730, China.
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Saccomanno MF, Sircana G, Masci G, Cazzato G, Florio M, Capasso L, Passiatore M, Autore G, Maccauro G, Pola E. Allergy in total knee replacement surgery: Is it a real problem? World J Orthop 2019; 10:63-70. [PMID: 30788223 PMCID: PMC6379738 DOI: 10.5312/wjo.v10.i2.63] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/26/2018] [Accepted: 01/06/2019] [Indexed: 02/06/2023] Open
Abstract
Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.
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Affiliation(s)
- Maristella F Saccomanno
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giuseppe Sircana
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giulia Masci
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Gianpiero Cazzato
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Michela Florio
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Luigi Capasso
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Marco Passiatore
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giovanni Autore
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giulio Maccauro
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Enrico Pola
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
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Alijotas-Reig J, Esteve-Valverde E, Gil-Aliberas N, Garcia-Gimenez V. Autoimmune/inflammatory syndrome induced by adjuvants-ASIA-related to biomaterials: analysis of 45 cases and comprehensive review of the literature. Immunol Res 2019; 66:120-140. [PMID: 29199390 DOI: 10.1007/s12026-017-8980-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Systemic autoimmune or granulomatous disorders related to biomaterials of human use have rarely been described. The aim of this study was to report cases of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) related to biomaterial injections and prostheses, mainly silicone, hyaluronic acid, acrylamides and methacrylate compounds in a Spanish patient cohort. This study is a retrospective analysis of clinical, laboratory, histopathological and follow-up data of 45 cases of patients suffering from late-onset, non-infectious inflammatory/autoimmune disorders related to bioimplants. Late onset was defined as 3 months or more post injection. Data were obtained through a further non-systematic but comprehensive review of the literature. Forty-five cases of late-onset adverse reactions related to biomaterial injections or prostheses were reviewed. All cases had systemic complaints that could be categorised as ASIA. In all but four patients, inflammatory features at the implantation site preceded distant or systemic manifestations. Abnormal blood tests were common. Localised inflammatory nodules and panniculitis in 40/45 (88.88%) evolved into a variety of disorders, viz., primary biliary cirrhosis, Sjögren's syndrome, sarcoidosis, human adjuvant disease, vasculitis, inflammatory bowel syndrome and inflammatory polyradiculopathy. Five (11.11%) cases presented primarily with systemic autoimmune disorders. Biomaterials and prostheses can provoke late-onset systemic autoimmune disorders fulfilling ASIA criteria, or present primarily local/regional inflammatory reactions that may eventually evolve into systemic autoimmune and/or granulomatous disorders which fall under ASIA.
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Affiliation(s)
- Jaume Alijotas-Reig
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine-1, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | | | - Natalia Gil-Aliberas
- Department of Internal Medicine, Althaia Network Health, Manresa, Barcelona, Spain
| | - Victor Garcia-Gimenez
- Europe Medical Centre, Barcelona, Spain.,Spanish Society of Cosmetic Medicine & Surgery, Barcelona, Spain
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Postler A, Beyer F, Lützner C, Tille E, Lützner J. Similar outcome during short-term follow-up after coated and uncoated total knee arthroplasty: a randomized controlled study. Knee Surg Sports Traumatol Arthrosc 2018; 26:3459-3467. [PMID: 29616285 DOI: 10.1007/s00167-018-4928-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/28/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE Patients with known hypersensitivity to metals often require hypoallergenic TKA implants. Coating of a standard implant is a common solution, and although in vitro tests have demonstrated reduction of polyethylene wear for these coatings, it is still unknown whether these implants have any clinical benefit. This study was initiated to investigate metal ion concentrations, knee function and patient-reported outcome (PRO) after coated and uncoated TKA. METHODS One hundred and twenty-two (122) patients were randomized to receive a coated or a standard TKA and, after exclusions, 59 patients were included in each group. Knee function and PRO were assessed with validated scores up to 3 years after surgery. Metal ion concentrations in blood samples were determined for chromium, cobalt, molybdenum and nickel, preoperatively and 1 year after surgery. RESULTS Chromium concentrations in patient plasma increased from a median of 0.25 to 1.30 µg/l in the standard TKA group, and from 0.25 to 0.75 µg/l in the coated TKA group (p = 0.012). Thirteen patients (3 coated, 10 standard TKA) had chromium concentrations above 2 µg/l. The concentrations of cobalt, molybdenum and nickel did not change. Patient-reported outcome measures (PROM) demonstrated a substantial improvement after TKA, without any differences between the groups. CONCLUSION The increase in chromium concentration in the standard group needs further investigation. If surgeons use coated implants, they can be confident that these implants perform as well as standard implants. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Anne Postler
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Franziska Beyer
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Cornelia Lützner
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Eric Tille
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Jörg Lützner
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
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Yan H, Afroz S, Dalanon J, Goto N, Hosoki M, Matsuka Y. Metal allergy patient treated by titanium implant denture: A case report with at least 4-year follow-up. Clin Case Rep 2018; 6:1972-1977. [PMID: 30349710 PMCID: PMC6186882 DOI: 10.1002/ccr3.1753] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/08/2018] [Indexed: 11/19/2022] Open
Abstract
Patch testing with metal reagents was positive on female patient with history of metal hypersensitivity after dental treatment. All of the dental restorations with metal components were removed, and subsequent oral rehabilitation utilizing dental implants and metal-free prostheses was carried out. The treatments alleviate the presenting signs and symptoms.
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Affiliation(s)
- Huijiao Yan
- Department of Stomatognathic Function and Occlusal ReconstructionGraduate School of Biomedical SciencesTokushima UniversityTokushimaJapan
| | - Shaista Afroz
- Department of Stomatognathic Function and Occlusal ReconstructionGraduate School of Biomedical SciencesTokushima UniversityTokushimaJapan
| | - Junhel Dalanon
- Department of Stomatognathic Function and Occlusal ReconstructionGraduate School of Biomedical SciencesTokushima UniversityTokushimaJapan
| | - Nami Goto
- Department of Stomatognathic Function and Occlusal ReconstructionGraduate School of Biomedical SciencesTokushima UniversityTokushimaJapan
| | - Maki Hosoki
- Department of Stomatognathic Function and Occlusal ReconstructionGraduate School of Biomedical SciencesTokushima UniversityTokushimaJapan
| | - Yoshizo Matsuka
- Department of Stomatognathic Function and Occlusal ReconstructionGraduate School of Biomedical SciencesTokushima UniversityTokushimaJapan
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Phedy P, Djaja YP, Boedijono DR, Wahyudi M, Silitonga J, Solichin I. Hypersensitivity to orthopaedic implant manifested as erythroderma: Timing of implant removal. Int J Surg Case Rep 2018; 49:110-114. [PMID: 30005360 PMCID: PMC6037004 DOI: 10.1016/j.ijscr.2018.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 06/06/2018] [Accepted: 06/16/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Incidence of hypersensitivity to orthopaedic implant, once estimated in less than 1% of population, recently has increased to 10%. Controversies about the timing of implant removal remain, especially due to the fact that implant hypersensitivity may be a contributing factor to implant failure. We present a case report and literature reviews to establish the decision making for the timing of implant removal in the presence of implant hypersensitivity. PRESENTATION OF CASE Female, 42 years old with nonunion of mid-shaft tibia and fibula which was treated with ORIF with conventional SAE16 stainless steel plate and bone graft. A week after, she developed a generalized rash, which is later diagnosed as erythroderma, that relapsed despite adequate systemic corticosteroid. Poor healing of surgical site wound were marked. After the implant removal, the cutaneous condition improved and no relapse were found. DISCUSSION Management of hypersensitivity to implants involved corticosteroid administration, removal or replacement of implants, or implants coating with polytetrafluoroethylene. Currently there are no specific guidelines regulating the management of implant allergy based on the timing of the onset, especially in fracture cases. The decision-making would be straightforward if union was already achieved. Otherwise, controversies would still occur. In this paper, we proposed an algorithm regarding the steps in managing metal allergy due to implant in fracture cases. CONCLUSION Despite the concerns regarding implant survival in hypersensitivity cases, the decision whether the implant should be removed or replaced should be based on the time and condition of the fracture healing process.
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Affiliation(s)
- Phedy Phedy
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Yoshi P Djaja
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Dimas R Boedijono
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Muhammad Wahyudi
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Jamot Silitonga
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Iman Solichin
- Rumah Sakit Orthopaedi Purwokerto, Purwokerto, Indonesia.
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Furrer S, Scherer Hofmeier K, Grize L, Bircher AJ. Metal hypersensitivity in patients with orthopaedic implant complications-A retrospective clinical study. Contact Dermatitis 2018; 79:91-98. [PMID: 29888396 DOI: 10.1111/cod.13032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/15/2018] [Accepted: 04/19/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hypersensitivity to metals as a cause of implant-related complications has been a subject of controversy. Projections indicate an increase in the frequency of joint replacements of between 300% and 600% by the year 2030; therefore, this issue is of considerable interest. OBJECTIVE To evaluate sensitization to implant materials in patients with implant-related complications, to identify allergens, and to clarify whether hypersensitivity is a relevant cause. METHODS Patients with implant-related complications or a positive history of contact allergy and planned total joint replacements referred for allergological investigation between 2004 and 2017 were retrospectively analysed. RESULTS In total, 311 patients were included. A positive patch test reaction to a metal was seen in 64.4% of preoperative patients and in 54.6% of patients with implant-related complications. Common alloy metals such as cobalt, chromium and titanium gave positive reactions in up to 2.9% of patients with implant-related complications. None of the patients with skin changes had a positive patch test reaction to an implant metal. CONCLUSION Other factors, such as the type of replaced joint and mechanical stress, seem to be more relevant for implant-related complications. Sensitization to metals or other materials seems to rarely play a role, and is overestimated.
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Affiliation(s)
- Stefan Furrer
- Department of Dermatology, Allergy Unit, University Hospital, Basel, Switzerland
| | | | - Leticia Grize
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Andreas J Bircher
- Department of Dermatology, Allergy Unit, University Hospital, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Høl PJ, Kristoffersen EK, Gjerdet NR, Pellowe AS. Novel Nanoparticulate and Ionic Titanium Antigens for Hypersensitivity Testing. Int J Mol Sci 2018; 19:E1101. [PMID: 29642398 PMCID: PMC5979587 DOI: 10.3390/ijms19041101] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/26/2018] [Accepted: 04/03/2018] [Indexed: 02/06/2023] Open
Abstract
Titanium is used in a wide variety of materials ranging from medical devices to materials used in everyday life. Adverse biological reactions that could occur in patients, consumers, and workers should be monitored and prevented. There is a lack of available agents to test and predict titanium-related hypersensitivity. The aim of this study was to develop two bioavailable titanium substances in ionic and nanoparticulate form to serve as antigens for hypersensitivity testing in vitro. Peripheral blood mononuclear cells from 20 test subjects were stimulated with the antigens and secretion of monocytic and lymphatic cytokines and chemokines were measured by a multiplex bead assay. Lymphocyte stimulation indices were also determined in a subset of test subjects by measuring CD69 and HLA-DR expression by flow cytometry. Cytokine profiling revealed that both antigens increased production of typical monocyte and macrophage secreted cytokines after 24 h, with significant increases in IL-1β, IL-7, IL-10, IL-12, IL-2R, IL-6, GM-CSF, TNF-α, IL-1RA, MIP-1α, MIP-1β, IFN-α, and IL-15. Lymphatic cytokines and chemokines were not significantly induced by activation. After seven days of stimulation, ionic-Ti (2.5 μg/mL) caused proliferation (stimulation index > 2) of CD4+ cells and CD8+ cells in all persons tested (N = 6), while titanium dioxide nanoparticles (50 μg/mL) only caused significant proliferation of CD4+ cells. Our preliminary results show that the experimental titanium antigens, especially the ionic form, induce a general inflammatory response in vitro. A relevant cohort of test subjects is required to further elucidate their potential for predictive hypersensitivity testing.
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Affiliation(s)
- Paul Johan Høl
- Department of Clinical Medicine, University of Bergen, N-5021 Bergen, Norway.
- Department of Orthopaedic Surgery, Haukeland University Hospital, Jonas Lies vei 87, N-5021 Bergen, Norway.
| | - Einar K Kristoffersen
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway.
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, N-5021 Bergen, Norway.
| | - Nils Roar Gjerdet
- Department of Clinical Dentistry, University of Bergen, N-5009 Bergen, Norway.
| | - Amanda S Pellowe
- School of Engineering and Applied Sciences, Yale University, New Haven, CT 06511, USA.
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Kilb BKJ, Kurmis AP, Parry M, Sherwood K, Keown P, Masri BA, Duncan CP, Garbuz DS. Frank Stinchfield Award: Identification of the At-risk Genotype for Development of Pseudotumors Around Metal-on-metal THAs. Clin Orthop Relat Res 2018; 476. [PMID: 29529651 PMCID: PMC6259707 DOI: 10.1007/s11999.0000000000000028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Once touted as the future of hip arthroplasty, metal-on-metal (MoM) bearing surfaces have fallen sharply from favor with the emergence of a strong body of evidence demonstrating unacceptably high premature implant failure rates. The previously unpredictable development of adverse local tissue reactions (ALTRs) has been a substantive contributor to this. Although the underlying pathophysiology of these so-called "pseudotumors" is now well understood, the fundamental predisposing patient risk factors have remained elusive. QUESTIONS/PURPOSES The aim of this research, as a clinical-genotype correlation analysis, was to identify specific alleles (genes) associated with the development of ALTRs in patients with in situ MoM THAs. METHODS A case-control study of patients who received a large-head, primary MoM THA between 2005 and 2008 was performed with a minimum followup of 5 years. Twenty-six patients who had undergone revision of a primary MoM THA secondary to symptomatic ALTRs were recruited. The mean timeframe from primary MoM THA to symptomatic revision was 5.5 years (range, 1-10 years). Twenty-eight control subjects were randomly selected asymptomatic patients with no evidence of ALTRs on protocol-specific screening. Baseline demographics and high-resolution genotype (human leukocyte antigen [HLA] Class II) were collected for all patients. Cohorts were similar with respect to age at the time of primary MoM THA (mean, 54.8 versus 54.9 years, p = 0.95) and serum cobalt (mean, 5.5 versus 8.5 μg/L, p = 0.09) and chromium concentrations (mean, 2.9 versus 4.2 μg/L, p = 0.27). The association between genotype and revision surgery secondary to ALTRs was determined with gender as a covariate. RESULTS The prevalence of the risk genotype was 30% (16 of 54) among the entire cohort. Adjusting for sex, the odds of revision were 6.1 times greater among patients with the risk genotype present than among patients without (95% confidence interval [CI], 1.5-25.4; p = 0.01). Among females, the specificity of the risk genotype was 1.0 (95% CIexact, 0.5-1.0; pexact = 0.03), and for males, it was 0.8 (95% CIexact, 0.6-0.9; pexact < 0.01). CONCLUSIONS The findings of this study suggest that, among patients with a primary MoM THA, allelic variation within the HLA Class II loci may be a strong, independent risk factor associated with the need for subsequent revision surgery secondary to pseudotumor formation. CLINICAL RELEVANCE Given the hypothesis-generating nature of this novel undertaking, confirmatory prospective clinical studies are required to further elucidate this correlation and to explore the clinical utility of targeted genetic screening in this specific population. This research may, however, represent a key missing piece in the puzzle that is metal ion-induced pseudotumor formation.
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Affiliation(s)
- Brett K J Kilb
- B. K. J. Kilb, A. P. Kurmis, M. Parry, B. A. Masri, C. P. Duncan, D. S., Garbuz Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada K. Sherwood, P. Keown Department of Pathology (&) Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada P. Keown, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada A. P. Kurmis, Discipline of Medical Specialties, University of Adelaide, Adelaide, SA, Australia
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Peat F, Coomber R, Rana A, Vince A. Vanadium allergy following total knee arthroplasty. BMJ Case Rep 2018; 2018:bcr-2017-222092. [PMID: 29351933 DOI: 10.1136/bcr-2017-222092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Allergic reactions to metals following joint arthroplasty represent a rare and poorly understood phenomenon. Much is still unknown regarding the natural history of this complication, and how it can best be prevented and managed. We present a case of a 68-year-old woman who underwent a left total knee arthroplasty for treatment of osteoarthritis. After an initial uneventful postoperative course, she developed a troublesome erythematous rash both around the incision site and over her trunk. Blood testing revealed no evidence of infection and clinically her prosthesis was functioning well. Skin patch testing revealed positive results for vanadium (+) and palladium (+). Her cutaneous symptoms are currently being managed conservatively and have shown a partial response to topical steroids. Revision surgery remains a long-term treatment option should conservative therapy fail; however, it would require a custom-made prosthesis as no standard tibial component is free from vanadium.
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Affiliation(s)
- Fidel Peat
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - Ross Coomber
- Trauma and Orthopaedics, Luton and Dunstable University Hospital, Luton, UK
| | - Adnan Rana
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - Alastair Vince
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
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Ayers R, Miller M, Schowinsky J, Burger E, Patel V, Kleck C. Three cases of metallosis associated with spine instrumentation. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2017; 29:3. [PMID: 29196871 DOI: 10.1007/s10856-017-6011-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/23/2017] [Indexed: 06/07/2023]
Abstract
The characteristic trait of metallosis is the presence of tissue staining. Analyzing explanted revision hardware from spine surgeries and performing ICPMS/AES analysis on removed tissue samples, a clinically relevant definition for metallosis may be developed. Results of the analysis identified hardware fretting wear and corrosion, and ICP-MS/AES analysis identified elevated metal ion concentrations in all cases. This supports the hypothesis that corrosion may be linked to poor health outcomes and potential need for revision surgery. Using failure analysis methods, corrosion products from orthopedic spine implants can be identified to begin to characterize metallosis in a clinically relevant manner. Failure analysis for patients undergoing revision spine surgery for other causes. Using failure analysis methods we conducted a retrieval analysis of explanted hardware and tissue. Implant failure with surrounding tissue metal staining is a current issue in the field of orthopedics. Specifically in spine, this issue is under reported and over looked as a clinically significant finding. Metallosis is most commonly used to describe the presence of tissue staining however this is not a clinically relevant definition. There is a need for further research to provide a better understanding of metallosis leading to better patient outcomes. Patients were screened for this study during a radiological review prior to surgery. All explanted hardware was documented and inspected for signs of wear and corrosion using non-destructive testing. A tissue sample that is normally removed and discarded was collected for ICP-MS/AES analysis. The presence of fretting corrosion, galling and corrosion fatigue was found on all explanted hardware. Cr levels are significantly higher than what was previously published as normal in muscle 0.03 μg/g. One case was a 4 order of magnitude elevation with the other 2 approximately 2 orders of magnitude increase. Titanium and Co concentrations are also significantly increased. The Ca to P ratio for all samples is approximately 1.7:1 suggesting some form of apatitic crystal present due to drying of the tissues. In all cases, the Al, Mo, V, Co, content in surrounding tissue is significantly elevated >10× above "normal," 8.4 ± 4.8; 1.61 ± 1.41; 0.06 ± 0.03; 1.35 ± 1.97 μg/g respectively. A "normal" reference titanium level could only be found for whole blood, 0.00072 ± 0.1412 μ/g. Iron and Ni measurements are within typical values presented in previous studies. No single mechanism for the release of metal ion in a patient is clear. Evidence suggests a tribocorrosive process due to both wear and environmental factors. Specific biologic mechanisms, such as the possible presence of bacteria may affect the fretting and corrosion of spinal instrumentation must be explored in conjunction with thorough review of patient outcomes. Such an effort can potentially reduce patient readmission and increase successful patient outcomes.
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Affiliation(s)
- Reed Ayers
- Department of Orthopedics, University of Colorado, School of Medicine, 12631 E. 17th Avenue, B202 Room 4603, Aurora, CO, 80045, USA.
| | - Mackenzie Miller
- Department of Orthopedics, University of Colorado, School of Medicine, 12631 E. 17th Avenue, B202 Room 4603, Aurora, CO, 80045, USA
| | - Jeffery Schowinsky
- Department of Orthopedics, University of Colorado, School of Medicine, 12631 E. 17th Avenue, B202 Room 4603, Aurora, CO, 80045, USA
| | - Evalina Burger
- Department of Orthopedics, University of Colorado, School of Medicine, 12631 E. 17th Avenue, B202 Room 4603, Aurora, CO, 80045, USA
| | - Vikas Patel
- Department of Orthopedics, University of Colorado, School of Medicine, 12631 E. 17th Avenue, B202 Room 4603, Aurora, CO, 80045, USA
| | - Christopher Kleck
- Department of Orthopedics, University of Colorado, School of Medicine, 12631 E. 17th Avenue, B202 Room 4603, Aurora, CO, 80045, USA
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49
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Christensen TJ, Samant SA, Shin AY. Making Sense of Metal Allergy and Hypersensitivity to Metallic Implants in Relation to Hand Surgery. J Hand Surg Am 2017; 42:737-746. [PMID: 28709788 DOI: 10.1016/j.jhsa.2017.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 06/12/2017] [Indexed: 02/02/2023]
Abstract
All metals implanted into a biological system undergo some degree of corrosion depending upon its composition. The electrochemical process of corrosion produces free metal ions, which may activate the host's immune system through a variety of mechanisms. Whereas dermal metal hypersensitivity is common, affecting 10% to 15% of the population, the immune reaction from implanted metals is much less common (< 0.1%), but has been associated with metal allergy and hypersensitivity producing a multitude of patient symptoms. Superficial symptoms may be mild to severe forms of dermatitis, urticaria, pruritus, and vasculitis, whereas deep sequelae include metallosis-related pseudotumor, implant loosening, and joint stiffness. Currently, there are clinical tests to evaluate patients for metal hypersensitivity, but there is little agreement regarding the ideal timing and clinical situation prompting the work-up of a patient for a metal allergy or hypersensitivity. An understanding of the epidemiology, etiology, basic science, diagnostic testing, and treatment of patients with suspected metal allergy, as it pertains to the current literature, will aid orthopedic and plastic surgeons of all subspecialties in the management of patients requiring metallic implants.
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Affiliation(s)
| | | | - Alexander Y Shin
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN.
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50
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Poddighe D, Vadalà M, Laurino C, Palmieri B. Somatoform and neurocognitive syndromes after HPV immunization are not associated to cell-mediated hypersensitivity to aluminum. Toxicol In Vitro 2017; 43:58-61. [PMID: 28599844 DOI: 10.1016/j.tiv.2017.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/25/2017] [Accepted: 06/04/2017] [Indexed: 01/09/2023]
Abstract
Vaccines against human papilloma virus (HPV) have been demonstrated to be very effective to prevent infection-related neoplasms. However, several reports describing heterogeneous post-vaccination phenomena have been published in last few years. The spectrum of these disorders includes both immune-mediated neurological diseases and neuropsychiatric functional disorders. Some researchers speculated about a genetic predisposition, but others hypothesized a role of adjuvants, including some metals and, particularly, aluminum. Here, we tested sixteen young girls developing somatoform and neurocognitive syndromes after the HPV immunization, through MELISA® test, detecting cell-mediated hypersensitivity to several metals. We found no association between these neurocognitive disorders and the results provided by this test; importantly, no patients showed hypersensitivity to aluminum, which is the inorganic adjuvant included in HPV vaccines. Thus, if aluminum played a role in the pathophysiology of musculoskeletal and neurocognitive disturbances occurring in some young girls after HPV immunization, that should recognize other mechanisms than the activation of aluminum-specific lymphocytes.
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Affiliation(s)
- Dimitri Poddighe
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Maria Vadalà
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy
| | - Carmen Laurino
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy
| | - Beniaminoi Palmieri
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy
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