Metal Hypersensitivity and Total Knee Arthroplasty

Abstract

Metal hypersensitivity in patients with a total knee arthroplasty (TKA) is a controversial topic. The diagnosis is difficult, given the lack of robust clinical validation of the utility of cutaneous and in vitro testing. Metal hypersensitivity after TKA is quite rare and should be considered after eliminating other causes of pain and swelling, such as low-grade infection, instability, component loosening or malrotation, referred pain, and chronic regional pain syndrome. Anecdotal observations suggest that two clinical presentations of metal hypersensitivity may occur after TKA: dermatitis or a persistent painful synovitis of the knee. Patients may or may not have a history of intolerance to metal jewelry. Laboratory studies, including erythrocyte sedimentation rate, C-reactive protein level, and knee joint aspiration, are usually negative. Cutaneous and in vitro testing have been reported to be positive, but the sensitivity and specificity of such testing has not been defined. Some reports suggest that, if metal hypersensitivity is suspected and nonsurgical measures have failed, then revision to components fabricated of titanium alloy or zirconium coating can be successful in relieving symptoms. Revision should be considered as a last resort, however, and patients should be informed that no evidence-based medicine is available to guide the management of these conditions, particularly for decisions regarding revision. Given the limitations of current testing methods, the widespread screening of patients for metal allergies before TKA is not warranted.

Figure 1

Clinical photograph demonstrating cutaneous patch testing on the upper back of a female patient who has persistent pain, synovitis, and stiffness after a total knee arthroplasty with an implant of a cobalt-chromium alloy. A mild allergic reaction to nickel, consisting of erythema and edema, is shown in the upper left box. (Courtesy of Audrey Echt, MD, Raleigh, NC.)

Figure 2

High-power photomicrograph (hematoxylin-eosin, magnification ×125) demonstrating a membrane adjacent to a femoral component of a cobalt-chromium alloy in a patient with painful, persistent synovitis after total knee arthroplasty. Chronic inflammation is present, and the predominant cells are lymphocytes (yellow arrow) and plasma cells (blue arrows). No multinuclear giant cells and no polyethylene fragments are evident. The synovial biopsies showed the same pattern. (Courtesy of Maureen Bauer, MD, Durham, NC.)