Skip to main content

Advertisement

SpringerLink
Log in

Allergy in Total Knee Replacement. Does It Exist?

Review Article

  • Global Tribology Summit
  • Published:
HSS Journal ®

Abstract

Background

There is little data on whether preexisting allergies to implant materials and bone cement have an impact on the outcome of TKA.

Questions/Purposes

This review article analyzes the current literature to evaluate the prevalence and importance of metal and cement allergies for patients undergoing total knee arthroplasty.

Methods

A review of the literature was performed using the following search criteria: “knee,” “arthroplasty,” and “allergy” as well as “knee,” “arthroplasty,” and “hypersensitivity.”

Results

One hundred sixteen articles were identified on PubMed, Seventy articles could be excluded by reviewing the title and abstract leaving 46 articles to be included for this review. The majority of the studies cited patch testing as the gold standard for screening and diagnosis of hypersensitivity following TKA. There is consensus that patients with self-reported allergies against metals or bone cement and positive patch test should be treated with hypoallergenic materials or cementless TKA. Treatment options include the following: coated titanium or cobalt-chromium implants, ceramic, or zirconium oxide implants.

Conclusion

Allergies against implant materials and bone cement are rare. Patch testing is recommended for patients with self-reported allergies. The use of special implants is recommended for patients with a confirmed allergy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Anand A, McGlynn F, Jiranek W. Metal hypersensitivity: can it mimic infection? The Journal of Arthroplasty. 2009; 24(5): 826.e25-8.

    Article  Google Scholar 

  2. Atanaskova Mesinkovska N, Tellez A, Molina L, et al. The effect of patch testing on surgical practices and outcomes in orthopedic patients with metal implants. Archives of Dermatology. 2012; 148(6): 687-93.

    Article  PubMed  Google Scholar 

  3. Australian O. Association, Annual Report 2014. 2014.

    Google Scholar 

  4. Bader R, Bergschmidt P, Fritsche A, Ansorge S, Thomas P, Mittelmeier W. Alternative materials and solutions in total knee arthroplasty for patients with metal allergy. Der Orthopade. 2008; 37(2): 136-42.

    Article  CAS  PubMed  Google Scholar 

  5. Bader R, Mittelmeier W, Steinhauser E. Failure analysis of total knee replacement. Basics and methodological aspects of the damage analysis. Der Orthopade. 2006; 35(9): 896. 8-900, 2-3.

    Article  CAS  PubMed  Google Scholar 

  6. Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and systemic hypersensitivity reactions to metallic implants. Dermatitis : Contact, Atopic, Occupational, Drug. 2011; 22(2): 65-79.

    Google Scholar 

  7. Beecker J, Gordon J, Pratt M. An interesting case of joint prosthesis allergy. Dermatitis : Contact, Atopic, Occupational, Drug. 2009; 20(2): E4-9.

    Google Scholar 

  8. Bergschmidt P, Bader R, Kluess D, et al. Total knee replacement system with a ceramic femoral component versus two traditional metallic designs: a prospective short-term study. Journal of Orthopaedic Surgery (Hong Kong). 2013; 21(3): 294-9.

    Article  Google Scholar 

  9. Bergschmidt P, Bader R, Mittelmeier W. Metal hypersensitivity in total knee arthroplasty: revision surgery using a ceramic femoral component - a case report. The Knee. 2012; 19(2): 144-7.

    Article  PubMed  Google Scholar 

  10. Bergschmidt PB, Bader R, Ganzer D, et al. Ceramic Femoral Components in Total Knee Arthroplasty - Two Year Follow-Up Results of an International Prospective Multi-Centre Study. The Open Orthopaedics Journal. 2012; 6: 172-8.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Bloemke AD, Clarke HD. Prevalence of Self-Reported Metal Allergy in Patients Undergoing Primary Total Knee Arthroplasty. The Journal of Knee Surgery. 2015; 28(3): 243-6.

  12. Buchanan RA, Rigney ED Jr, Williams JM. Wear-accelerated corrosion of Ti-6Al-4V and nitrogen-ion-implanted Ti-6Al-4V: mechanisms and influence of fixed-stress magnitude. Journal of Biomedical Materials Research. 1987; 21(3): 367-77.

    Article  CAS  PubMed  Google Scholar 

  13. Carlsson A, Moller H. Implantation of orthopaedic devices in patients with metal allergy. Acta Dermato-Venereologica. 1989; 69(1): 62-6.

    CAS  PubMed  Google Scholar 

  14. Carlsson AS, Magnusson B, Moller H. Metal sensitivity in patients with metal-to-plastic total hip arthroplasties. Acta Orthopaedica Scandinavica. 1980; 51(1): 57-62.

    Article  CAS  PubMed  Google Scholar 

  15. Carulli C, Villano M, Bucciarelli G, Martini C, Innocenti M. Painful knee arthroplasty: definition and overview. Clinical Cases in Mineral and Bone Metabolism : The Official Journal of The Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases. 2011; 8(2): 23-5.

    Google Scholar 

  16. Dietrich KA, Mazoochian F, Summer B, Reinert M, Ruzicka T, Thomas P. Intolerance reactions to knee arthroplasty in patients with nickel/cobalt allergy and disappearance of symptoms after revision surgery with titanium-based endoprostheses. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG. 2009; 7(5): 410-3.

    PubMed  Google Scholar 

  17. Eben R, Dietrich KA, Nerz C, et al. Contact allergy to metals and bone cement components in patients with intolerance of arthroplasty. Deutsche Medizinische Wochenschrift (1946). 2010; 135(28-29): 1418-22.

    Article  CAS  Google Scholar 

  18. Edwards SA, Gardiner J. Hypersensitivity to benzoyl peroxide in a cemented total knee arthroplasty: cement allergy. The Journal of Arthroplasty. 2007; 22(8): 1226-8.

    Article  PubMed  Google Scholar 

  19. Elves MW, Wilson JN, Scales JT, Kemp HB. Incidence of metal sensitivity in patients with total joint replacements. British Medical Journal. 1975; 4(5993): 376-8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Evans EM, Freeman MA, Miller AJ, Vernon-Roberts B. Metal sensitivity as a cause of bone necrosis and loosening of the prosthesis in total joint replacement. J Bone Joint Surg Br. 1974; 56-b(4): 626-42.

    CAS  PubMed  Google Scholar 

  21. Fink U. Safety aspects in the coating of titanium slide components. Der Orthopade. 1997; 26(2): 160-5.

    CAS  PubMed  Google Scholar 

  22. Frigerio E, Pigatto PD, Guzzi G, Altomare G. Metal sensitivity in patients with orthopaedic implants: a prospective study. Contact Dermatitis. 2011; 64(5): 273-9.

    Article  CAS  PubMed  Google Scholar 

  23. Gallo J, Goodman SB, Konttinen YT, Wimmer MA, Holinka M. Osteolysis around total knee arthroplasty: a review of pathogenetic mechanisms. Acta Biomaterialia. 2013; 9(9): 8046-58.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Gao X, He RX, Yan SG, Wu LD. Dermatitis associated with chromium following total knee arthroplasty. The Journal of Arthroplasty. 2011; 26(4): 665.e13-6.

    Article  Google Scholar 

  25. Granchi D, Cenni E, Tigani D, Trisolino G, Baldini N, Giunti A. Sensitivity to implant materials in patients with total knee arthroplasties. Biomaterials. 2008; 29(10): 1494-500.

    Article  CAS  PubMed  Google Scholar 

  26. Graves CM, Otero JE, Gao Y, Goetz DD, Willenborg MD, Callaghan JJ. Patient reported allergies are a risk factor for poor outcomes in total hip and knee arthroplasty. The Journal of Arthroplasty. 2014; 29(9 Suppl): 147-9.

    Article  PubMed  Google Scholar 

  27. Haeberle M, Wittner B. Is gentamicin-loaded bone cement a risk for developing systemic allergic dermatitis? Contact Dermatitis. 2009; 60(3): 176-7.

    Article  PubMed  Google Scholar 

  28. Hallab NJ, Caicedo M, Finnegan A, Jacobs JJ. Th1 type lymphocyte reactivity to metals in patients with total hip arthroplasty. Journal of Orthopaedic Surgery and Research. 2008; 3: 6.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Handa S, Dogra S, Prasad R. Metal sensitivity in a patient with a total knee replacement. Contact Dermatitis. 2003; 49(5): 259-60.

    Article  PubMed  Google Scholar 

  30. Harman MK, Banks SA, Hodge WA. Wear Analysis of a Retrieved Hip Implant With Titanium Nitride Coating. The Journal of Arthroplasty. 1997; 12(8): 938-45.

    Article  CAS  PubMed  Google Scholar 

  31. Hendry JA, Pilliar RM. The fretting corrosion resistance of PVD surface-modified orthopedic implant alloys. Journal of Biomedical Materials Research. 2001; 58(2): 156-66.

    Article  CAS  PubMed  Google Scholar 

  32. Hofer JK, Ezzet KA. A minimum 5-year follow-up of an oxidized zirconium femoral prosthesis used for total knee arthroplasty. The Knee. 2014; 21(1): 168-71.

    Article  PubMed  Google Scholar 

  33. Innocenti M, Carulli C, Matassi F, Carossino AM, Brandi ML, Civinini R. Total knee arthroplasty in patients with hypersensitivity to metals. International Orthopaedics. 2014; 38(2): 329-33.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Kaplan K, Della Valle CJ, Haines K, Zuckerman JD. Preoperative identification of a bone-cement allergy in a patient undergoing total knee arthroplasty. The Journal of Arthroplasty. 2002; 17(6): 788-91.

    Article  PubMed  Google Scholar 

  35. Krecisz B, Kiec-Swierczynska M, Bakowicz-Mitura K. Allergy to metals as a cause of orthopedic implant failure. International Journal of Occupational Medicine and Environmental Health. 2006; 19(3): 178-80.

    Article  PubMed  Google Scholar 

  36. Krenn V, Morawietz L, Kienapfel H, et al. Revised consensus classification. Histopathological classification of diseases associated with joint endoprostheses. Zeitschrift fur Rheumatologie. 2013; 72(4): 383-92.

    Article  CAS  PubMed  Google Scholar 

  37. Krenn V, Morawietz L, Perino G, et al. Revised histopathological consensus classification of joint implant related pathology. Pathology, Research and Practice. 2014; 210(12): 779-86.

    Article  CAS  PubMed  Google Scholar 

  38. Lappalainen R, Santavirta SS. Potential of Coatings in Total Hip Replacement. Clinical Orthopaedics and Related Research. 2005; 430: 72-9.

    Article  Google Scholar 

  39. Lieberman P, Fonacier L. Systemic contact dermatitis possibly related to metal implants. The Journal of Allergy and Clinical Immunology In Practice. 2014; 2(4): 487.

    Article  PubMed  Google Scholar 

  40. Lutzner J, Hartmann A, Dinnebier G, Spornraft-Ragaller P, Hamann C, Kirschner S. Metal hypersensitivity and metal ion levels in patients with coated or uncoated total knee arthroplasty: a randomised controlled study. International Orthopaedics. 2013; 37(10): 1925-31.

    Article  PubMed  PubMed Central  Google Scholar 

  41. McLawhorn AS, Bjerke-Kroll BT, Blevins JL, Sculco PK, Lee YY, Jerabek SA. Patient-Reported Allergies Are Associated With Poorer Patient Satisfaction and Outcomes After Lower Extremity Arthroplasty: A Retrospective Cohort Study. The Journal of Arthroplasty. 2015; 30(7): 1132-6.

  42. Meyer H, Kruger A, Roessner A, Lohmann CH. Allergic reactions as differential diagnosis for periprosthetic infection. Der Orthopade. 2012; 41(1): 26-31.

    Article  CAS  PubMed  Google Scholar 

  43. Mitchelson AJ, Wilson CJ. Biomaterial Hypersensitivity: Is It Real? Supportive Evidence and Approach Considerations for Metal Allergic Patients following Total Knee Arthroplasty. BioMed Research International. 2015; 2015: 137287.

  44. Morawietz L, Krenn V. The spectrum of histomorphological findings related to joint endoprosthetics. Der Pathologe. 2014; 35 Suppl 2: 218-24.

    Article  CAS  PubMed  Google Scholar 

  45. Munch HJ, Jacobsen SS, Olesen JT, et al. The association between metal allergy, total knee arthroplasty, and revision: study based on the Danish Knee Arthroplasty Register. Acta Orthopaedica. 2015; 86(3): 378-83.

  46. Nasser S. Orthopedic metal immune hypersensitivity. Orthopedics. 2007; 30(8 Suppl): 89-91.

    PubMed  Google Scholar 

  47. Niki Y, Matsumoto H, Otani T, et al. Screening for symptomatic metal sensitivity: a prospective study of 92 patients undergoing total knee arthroplasty. Biomaterials. 2005; 26(9): 1019-26.

    Article  CAS  PubMed  Google Scholar 

  48. Pellengahr C, Mayer W, Maier M, et al. Resurfacing knee arthroplasty in patients with allergic sensitivity to metals. Archives of Orthopaedic and Trauma Surgery. 2003; 123(4): 139-43.

    CAS  PubMed  Google Scholar 

  49. Post ZD, Orozco FR, Ong AC. Metal sensitivity after TKA presenting with systemic dermatitis and hair loss. Orthopedics. 2013; 36(4): e525-8.

    Article  PubMed  Google Scholar 

  50. Raimondi MT, Pietrabissa R. The in-vivo wear performance of prosthetic femoral heads with titanium nitride coating. Biomaterials. 2000; 21(9): 907-13.

    Article  CAS  PubMed  Google Scholar 

  51. Rau C, Thomas P, Thomsen M. Metal sensitivity in patients with joint replacement arthroplasties before and after surgery. Der Orthopade. 2008; 37(2): 102-10.

    Article  CAS  PubMed  Google Scholar 

  52. Reed KB, Davis MD, Nakamura K, Hanson L, Richardson DM. Retrospective evaluation of patch testing before or after metal device implantation. Archives of Dermatology. 2008; 144(8): 999-1007.

    Article  PubMed  Google Scholar 

  53. Schalock PC, Menne T, Johansen JD, et al. Hypersensitivity reactions to metallic implants - diagnostic algorithm and suggested patch test series for clinical use. Contact Dermatitis. 2012; 66(1): 4-19.

    Article  CAS  PubMed  Google Scholar 

  54. Schuh A, Lill C, Honle W, Effenberger H. Prevalence of allergic reactions to implant materials in total hip and knee arthroplasty. Zentralblatt fur Chirurgie. 2008; 133(3): 292-6.

    Article  CAS  PubMed  Google Scholar 

  55. Schuh A, Thomas P, Reinhold R, Holzwarth U, Zeiler G, Mahler V. Allergic reaction to components of bone cement after total knee arthroplasty. Zentralblatt fur Chirurgie. 2006; 131(5): 429-31.

    Article  CAS  PubMed  Google Scholar 

  56. Smith&Nephew. www.smith-nephew.com. 2012. Available from: http://www.smith-nephew.com/key-products/orthopaedic-reconstruction/oxinium-oxidized-zirconium/.

    Google Scholar 

  57. Streicher RM, Weber H, Schon R, Semlitsch M. New surface modification for Ti-6Al-7Nb alloy: oxygen diffusion hardening (ODH). Biomaterials. 1991; 12(2): 125-9.

    Article  CAS  PubMed  Google Scholar 

  58. Thakur RR, Ast MP, McGraw M, Bostrom MP, Rodriguez JA, Parks ML. Severe persistent synovitis after cobalt-chromium total knee arthroplasty requiring revision. Orthopedics. 2013; 36(4): e520-4.

    Article  PubMed  Google Scholar 

  59. Thienpont E, Berger Y. No allergic reaction after TKA in a chrome-cobalt-nickel-sensitive patient: case report and review of the literature. Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of The ESSKA. 2013; 21(3): 636-40.

    Article  Google Scholar 

  60. Thomas P, Summer B, Krenn V, Thomsen M. Allergy diagnostics in suspected metal implant intolerance. Der Orthopade. 2013; 42(8): 602-6.

    Article  CAS  PubMed  Google Scholar 

  61. Thomas P, von der Helm C, Schopf C, et al. Patients with Intolerance Reactions to TKA: Combined Assessment of Allergy Diagnostics, Periprosthetic Histology, and Peri-implant Cytokine Expression Pattern. BioMed Research International. 2014; 2014: 910156.

  62. Thomsen M, Rozak M, Thomas P. Pain in a chromium-allergic patient with total knee arthroplasty: disappearance of symptoms after revision with a special surface-coated TKA--a case report. Acta Orthopaedica. 2011; 82(3): 386-8.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Thomsen M, Rozak M, Thomas P. Use of allergy implants in Germany: results of a survey. Der Orthopade. 2013; 42(8): 597-601.

    Article  CAS  PubMed  Google Scholar 

  64. van Hove RP, Sierevelt IN, van Royen BJ, Nolte PA. Titanium-Nitride Coating of Orthopaedic Implants: A Review of the Literature. BioMed Research International. 2015; 2015: 485975.

  65. Van Opstal N, Verheyden F. Revision of a tibial baseplate using a customized oxinium component in a case of suspected metal allergy. A case report. Acta Orthopaedica Belgica. 2011; 77(5): 691-5.

    PubMed  Google Scholar 

  66. Verma SB, Mody B, Gawkrodger DJ. Dermatitis on the knee following knee replacement: a minority of cases show contact allergy to chromate, cobalt or nickel but a causal association is unproven. Contact Dermatitis. 2006; 54(4): 228-9.

    Article  PubMed  Google Scholar 

  67. Waterman AH, Schrik JJ. Allergy in hip arthroplasty. Contact Dermatitis. 1985; 13(5): 294-301.

    Article  CAS  PubMed  Google Scholar 

  68. Witzleb WC, Hanisch U, Kolar N, Krummenauer F, Guenther KP. Neo-capsule tissue reactions in metal-on-metal hip arthroplasty. Acta Orthopaedica. 2007; 78(2): 211-20.

    Article  PubMed  Google Scholar 

  69. Zeng Y, Feng W, Li J, et al. A prospective study concerning the relationship between metal allergy and post-operative pain following total hip and knee arthroplasty. International Orthopaedics. 2014; 38(11): 2231-6.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA

    Martin Faschingbauer MD, Lisa Renner MD & Friedrich Boettner MD

  2. Department of Orthopaedic Surgery, University of Ulm, RKU, Oberer Eselsberg 45, 89081, Ulm, Germany

    Martin Faschingbauer MD

  3. Department of Orthopedic Surgery, Charite Universitaetsmedizin, Center for Musculosceletal Surgery, Chariteplatz 1, 10117, Berlin, Germany

    Lisa Renner MD

Authors
  1. Martin Faschingbauer MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lisa Renner MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Friedrich Boettner MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Friedrich Boettner MD.

Ethics declarations

Conflict of Interest

Martin Faschingbauer, MD reports other from Deutsche Forschungsgemeinschaft, during the conduct of the study. Lisa Renner, MD has declared that she has no conflict of interest. Friedrich Boettner, MD reports personal fees from Smith & Nephew, during the conduct of the study; personal fees from Ortho Development, outside the work.

Human/Animal Rights

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed Consent

N/A

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Additional information

Work was performed at Hospital for Special Surgery.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(PDF 1224 kb)

ESM 2

(PDF 1224 kb)

ESM 3

(PDF 1224 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Faschingbauer, M., Renner, L. & Boettner, F. Allergy in Total Knee Replacement. Does It Exist?. HSS Jrnl 13, 12–19 (2017). https://doi.org/10.1007/s11420-016-9514-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11420-016-9514-8

Keywords

Search

Navigation