Aims. The treatment of patients with allergies to metal in total joint arthroplasty is an ongoing debate. Possibilities include the use of hypoallergenic prostheses, as well as the use of standard cobalt-chromium (CoCr) alloy. This non-designer study was performed to evaluate the clinical outcome and survival rates of unicondylar knee arthroplasty (UKA) using a standard CoCr alloy in patients reporting signs of a
We report a systematic review and meta-analysis
of the peer-reviewed literature focusing on metal sensitivity testing
in patients undergoing total joint replacement (TJR). Our purpose
was to assess the risk of developing
We explored the literature surrounding whether
allergy and hypersensitivity has a clinical basis for implant selection
in total knee arthroplasty (TKA). In error, the terms hypersensitivity
and allergy are often used synonymously. Although a relationship
is present, we could not find any evidence of implant failure due
to allergy. There is however increasing basic science that suggests
a link between loosening and metal ion production. This is not an
allergic response but is a potential problem. With a lack of evidence
logically there can be no justification to use ‘hypoallergenic’
implants in patients who have pre-existing skin sensitivity to the
metals used in TKA. Cite this article:
Aims. Metal allergy in knee arthroplasty patients is a controversial topic. We aimed to conduct a scoping review to clarify the management of metal allergy in primary and revision total knee arthroplasty (TKA). Methods. Studies were identified by searching electronic databases: Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and Embase, from their inception to November 2020, for studies evaluating TKA patients with
Total Knee Arthroplasty (TKA) patients may present with effusion, pain, stiffness and functional impairment. A positive
Introduction. Metal ion and particle release, particularly cobalt, has become an important subject in total hip arthroplasty, as it has shown to induce
Objectives. Modern metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), while achieving good results with well-orientated, well-designed components in ideal patients, is contraindicated in women, men with head size under 50 mm, or
Introduction. There are several potential biological mechanisms that may influence aseptic implant failure including excessive innate and adaptive immune responses to implant debris. We investigated the hypothesis that patients with painful total joint replacements will exhibit elevated levels of metal reactivity and inflammatory markers compared to patients with well-performing TJA. We evaluated this hypothesis by testing for
Introduction. Metals used for total knee arthroplasty (TKA) are well known for their good biocompatibility, but may be a source of a release of metal ions that can be a cause of local and systemic adverse effects, aseptic loosening, and hypersensitivity reactions. One of the major difficulties in performing TKA is the selection of implants for patients who are preoperatively diagnosed as subject to metal sensitivity. Alternative solutions in cases of hypersensitivity are implants without metal constituents or metallic implants treated with a non-sensitive surface process. The aim of this study was to evaluate clinical results in patients who had been preoperatively diagnosed with metal sensitivity and who subsequently were provided with the zirconia-ceramic LFA-III TKA, and with a minimum 5-year follow-up. Methods. Five patients (8 knees) with metal sensitivity underwent TKA using cemented zirconia-ceramic LFA-III implants. The LFA-III implant (KYOCERA Medical Co., Japan) is composed of a zirconia ceramic femoral component and a titanium-alloy tibial component with a polyethylene insert. All patients were female andthe average age at the time of surgery was 76.1 years. The average follow-up time was 7.2 years. Clinical and radiographic assessments were conducted with the Knee Society scoring system. Results. No patients except one who had palmoplantar pustulosis preoperatively presented systemic or local dermatitis after surgery. The mean preoperative range of motion of 97.6 degrees improved to a mean of 110.7 degrees at the time of the most recent follow-up. The mean postoperative knee and function scores were 77.1 and 66.9, respectively. Subtle periprosthetic radiolucencies were found in 2 knees after the surgery. Discussion. The zirconia-ceramic LFA-III TKA has performed well over a 5-year period in patients with
Metal-on-metal (MOM) hip arthroplasty has been associated with a variety of new failure modes that may be unfamiliar to surgeons who traditionally perform metal-on-polyethylene THR. These failure modes include adverse local tissue reaction to
Introduction. Modular femoral necks have shown promising clinical results in total hip arthroplasty (THA) to optimize offset, rotation, and leg length. Given the wide variety of proximal femoral morphology, fine-tuning these kinematic parameters can help decrease femoroacetabular impingement, decrease wear rates and help prevent dislocations. Yet, additional implant junctions introduce additional mechanisms of failure. We present two patients who developed an abnormal soft tissue reaction consistent with a
Introduction: Patient selection has been critical to the excellent medium-term clinical results following hip resurfacing. Hypersensivity to metal ion debris has been described in previous generations of metal-on-metal bearings. This may also be a problem that affects modern designs. Characteristic histological changes have been identified (ALVAL). There are few studies that include large female numbers, and show separate outcome and implant survival. Methods: Eighty-one female hips at a mean of 23 months (11–43) had an ASR hip resurfacing procedure at a single-surgeon independent centre. Mean age was 55 years (28–69). Harris Hip Scores (HHS) were recorded at one-year follow-up. Failures were analysed. Results: HHS improved from 46.4 (11–77) to 90.2 (27–100). Overall, there was a 7.4 % revision rate. There were 3 femoral neck fractures. In the entire series of 98 female patients there were 3 cases of severe pain requiring revision (3.1%). All three patients had HHS <
50 at one year follow-up. Patients had groin pain, reduced flexion and a painful straight leg raise. Blood results were not suggestive of infection. Aspiration of the hip joint in each case revealed copious amounts of milky green grey aseptic fluid. All had similar macroscopic changes at revision. There were characteristic histological changes in keeping with ALVAL. All 3 patients were revised to THRs with ceramic bearings. Discussion: The failure rate of 7.4% in the older female group is poor at this early stage following hip resurfacing. The incidence of
Only a little over a decade ago the vast majority of primary total hip replacements performed in North America, and indeed globally, employed a conventional polyethylene insert, either in a modular version or in a cemented application. Beginning in the early 2000's there was an explosion in technology and options available for the bearing choice in total hip arthroplasty. Highly crosslinked polyethylene was introduced in 1998, and within a few short years the vast majority of polyethylene inserts performed in North America were manufactured from this material. Globally there was a mixed picture with variable market penetration. Surgeons had seen historically poor results with attempts at “improving” polyethylene in the past and many were hesitant to use this new technology. Many randomised clinical trials have been performed and all have shown to a greater or lesser degree, that indeed the highly crosslinked polyethylene insert has undergone less linear and volumetric wear than its more conventional counterpart. The challenge, however, is as we approached mid-term results, orthopaedic manufacturers began altering the polyethylene to improve wear and improve mechanical strength. Therefore while ten-year and greater data will ultimately be published, the actual polyethylene in use at that time will be a different material. Additionally while wear rates are undoubtedly lower, we are still waiting for long-term results of actual osteolytic lesion development and the effect that highly crosslinked polyethylene will have on this clinical scenario. That being said, with over a decade of clinical experience, unquestionably highly crosslinked polyethylene has truly been a revolution in design, essentially eliminating polyethylene wear as an early failure mode. During this same decade metal-on-metal implants had seen a significant resurgence in use. Metal-on-metal implants had in-vitro advantages with very low wear rates. They allowed the use of large metal heads and articulations, thereby improving range of motion and stability. Concerns always existed regarding the production of metal ions and the potential for
Only a little over a decade ago the vast majority of primary total hip replacements performed in North America, and indeed globally, employed a conventional polyethylene insert, either in a modular version or in a cemented application. Beginning in the early 2000's there was an explosion in technology and options available for the bearing choice in total hip arthroplasty. Highly cross-linked polyethylene was introduced in 1998, and within a few short years the vast majority of polyethylene inserts performed in North America were manufactured from this material. Globally there was a mixed picture with variable market penetration. Surgeons had seen historically poor results with attempts at “improving” polyethylene in the past and many were hesitant to use this new technology. Many randomised clinical trials have been performed and all have shown to a greater or lesser degree, that indeed the highly cross-linked polyethylene insert has undergone less linear and volumetric wear than its more conventional counterpart. This replicates well the hip simulator data. The challenge however is as we approached mid-term results, orthopaedic manufacturers began altering the polyethylene to improve wear and improve mechanical strength. Therefore while ten-year and greater data will ultimately be published, the actual polyethylene in use at that time will be a different material. Additionally while wear rates are undoubtedly lower, we are still waiting for long-term results of actual osteolytic lesion development and the effect that highly cross-linked polyethylene will have on this clinical scenario. That being said, with over a decade of clinical experience, unquestionably highly cross-linked polyethylene has truly been a revolution in design, essentially eliminating polyethylene wear as an early failure mode. During this same decade metal-on-metal implants had seen a significant resurgence in use. Most major orthopaedic companies produced a metal-on-metal implant whether in the form of a more conventional modular insert, or a monoblock resurfacing-type implant, or both. Metal-on-metal implants had in-vitro advantages with very low wear rates. They allowed the use of large metal heads and articulations, thereby improving range of motion and stability. Concerns always existed regarding the production of metal ions and the potential for
The histopathology of periprosthetic tissues has been important to understanding the relationship between wear debris and arthroplasty outcome. In a landmark 1977paper, Willert and Semlitsch (1) used a semiquantitative rating to show that tissue reactions largely reflected the extent of particulate debris. Notably, small amounts of debris, including metal, could be eliminated without “overstraining the tissues” but excess debris led to deleterious changes. Currently, a plethora of terms is used to describe tissues from metal-on-metal (M-M) hips and corroded modular connections. We reviewed the evaluation and reporting of local tissue reactions over time, and asked if a dose response has been found between metal and tissue features, and how the use of more standardized terms and quantitative methodologies could reduce the current confusion in terminology. Methods. The PubMed database was searchedbetween 2000 and 2015 for papers using “metal sensitivity /allergy /hypersensitivity, Adverse Local Tissue Reaction (ALTR): osteolysis, metallosis, lymphocytic infiltration, Aseptic Lymphocytic Vasculitis-Associated Lesions (ALVAL), Adverse Reaction to Metal Debris (ARMD) or pseudotumor/ pseudotumour” as well as metal-on-metal / metal-metal AND hip arthroplasty/replacement. Reports lacking soft tissue histological analysis were excluded. Results. 131 articles describing M-M tissue histology were found. In earlier studies, the terms
Distal neck modularity places a modular connection at a mechanically critical location, which is also the location that confers perhaps the greatest clinical utility. The benefits of increased clinical options at that location must be weighed against the potential risks of adding an additional junction to the construct. Those risks include prosthetic neck fracture, taper corrosion,
There are a multitude of choices and implant varieties for primary total knee arthroplasty (TKA). TKA implant systems differ in a number of design characteristics intended to either improve performance through optimizing kinematic function (such as the medial pivot, mobile bearing, gender-specific or high-flexion designs) or by increasing the durability of the TKA by minimizing long-term failure modes, such as wear and osteolysis with highly cross-linked polyethylene. Further adding to the complexity of choice, is the re-emergence of cementless fixation in response to improve longevity in the progressively younger TKA patient population. The patella creates additional decision-making in TKA, as while most surgeons in the US resurface the patella, there are some who routinely do not which is a much more commonly accepted practice outside of the US. Finally,
Distal neck modularity places a modular connection at a mechanically critical location which is also the location that confers perhaps the greatest clinical utility. Assessment of femoral anteversion in 342 of our total hip replacement (THR) patients by CT showed a range from −24 to 61 degrees. The use of monoblock stems in some of these deformed femurs therefore must result in a failure to appropriately reconstruct the hip and have increased risks of impingement, instability, accelerated bearing wear or fracture, and adverse local tissue reaction (ALTR). However, the risks of failing to properly reconstruct the hip without neck modularity must be weighed against the additional risks introduced by neck modularity. There are several critical design, material, and technique variables that are directly associated with higher or lower incidences of problems associated with modular neck femoral components. Unfortunately, in vitro testing of the fatigue strength of these constructs has failed to predict their behavior in vivo. Designs predicted to tolerate loads that far exceed those experienced in vivo still fail at unacceptably high rates. Titanium alloy neck components subjected to the stresses at the neck-stem junction continue to fail at an unacceptable incidence. CoCr alloy neck components, while theoretically stronger, still fracture and are further compromised by mechanically assisted crevice corrosion,
Total joint arthroplasty has proven to be efficient to relieve pain and regain mobility. In fact, most patients undergoing a total knee arthroplasty (TKA) are satisfied with their surgery (80 to 90%), yet 4 to 7% still complain of unexplainable pain and stiffness. Several authors have proposed that reactivity to the implant could explain this phenomenon. Still, no strong evidence supports this theory as of today. We aimed to determine the prevalence of metal and cement hypersensitivity in a cohort of patients with unexplained pain and stiffness after TKA. We retrieved data for a group of patients presenting unexplained pain and stiffness. We excluded all other potential known causes of pain. All patients were tested with a Lymphocyte Transformation Test from whole blood taps. We analysed data of
Introduction. In recent years, an increasing number of reports related to adverse reactions to metal debris (ARMD) following metal-on-metal (MOM) total hip arthroplasty (THA) have been published. Some patients who experience ARMD require revision surgery. Objectives. In this study, we aimed to evaluate the mid-term results of MOM THA. Methods. We retrospectively reviewed all patients who underwent THA at JCHO Saitama medical center from January 2007 to December 2010. A metal liner and metal femoral head were used in 37 of 214 cases (17%). This sub-group comprised 2 men and 35 women (mean age at surgery, 63.5 years; range, 39–79 years). The original disease is 28 osteoarthritis, 5 osteonecrosis, 3 rheumatoid arthritis and 1 rapidly destructive hip coxarthropathy. We investigated the system type, size (cup, femoral head, and stem), and cup position (anteversion and inclination). Moreover, we used imaging (radiography and computed tomography [CT] or magnetic resonance imaging [MR]) to assess for aseptic loosening,
