Q:

10/31/2011

I have seen a few patients with no history of metal contact dermatitis who have problems after total knee replacement. Their complaints may be of soreness in knee, heaviness in knee and leg perhaps some swelling in the knee and leg. There is no rash. They have had a negative workup by Orthopedics who did various imaging studies. Orthopedics sends them for patch testing for metal. Have there been cases of patients with no history of contact dermatitis to metal that present with complaints after procedures involving metal? Is there a similar situation with various cement products? Thank you for your help.

A:

Thank you for your recent inquiry.

Yes, there is a rich body of literature of patients with no previous history of contact dermatitis to metals (as well as cements) in whom difficulties with prostheses and implants have been attributed to delayed hypersensitivity reactions. However, in order to document that difficulty with an implant or prosthesis is due to a delayed hypersensitivity reaction, a positive contact patch test is required. In many instances, tests are negative. Such tests are usually done with commercially available standard patch test kits for metals, and quite often with kits that are supplied by the manufacturer of the implant or prosthesis.

There are a number of excellent review articles on this topic. I have copied below links to several of these, and also one abstract as an example of the type of literature in this area.

Thank you again for your inquiry and we hope this response is helpful to you.

http://www.medscape.com/viewarticle/742801

[PDF]
A 61 Year-old Man With Delayed Hypersensitivity Reaction to Joint ...
jdc.jefferson.edu/cgi/viewcontent.cgi?article=1137&context=tmf

http://alloergo.yolasite.com/resources/2011%20-%20Hypersensitivity%20Reactions%20Metallic%20Implants.pdf

Early Osteolysis Following Second-Generation Metal-on-Metal Hip Replacement
Youn-Soo Park, MD1; Young-Wan Moon, MD1; Seung-Jae Lim, MD1; Jun-Mo Yang, MD1; Geunghwan Ahn, MD1; Yoon-La Choi, MD1
1 Departments of Orthopedic Surgery (Y.-S.P., Y.-W.M., S.-J.L.), Dermatology (J.-M.Y.), and Pathology (G.A., Y.-L.C.), Sungkyunkwan University School of Medicine, Samsung Medical Center, 50 Ilwong-dong, Kangnam-ku 135-710, Seoul, South Korea.
View Disclosures and Other Information
The Journal of Bone & Joint Surgery. 2005; 87:1515-1521 doi:10.2106/JBJS.D.0264
Abstract
Background: Total hip arthroplasty with use of metal-on-metal bearings has been reintroduced as an alternative to the use of metal-on-polyethylene bearings because of theoretical advantages such as reduced wear and a lower prevalence of osteolysis. However, we observed early osteolysis in a cohort of patients who had been managed with second-generation metal-on-metal hip replacements and investigated the possible etiologic role of metal hypersensitivity.
Methods: We retrospectively analyzed 165 patients (169 hips) who had undergone primary cementless total hip replacement with a contemporary metal-on-metal total hip design between 2000 and 2002. After a minimum duration of follow-up of twenty-four months, nine patients (ten hips) had an osteolytic lesion localized to the greater trochanter. Skin-patch tests for hypersensitivity to metals were performed on the nine patients and on nine randomly selected patients with total hip replacements who did not have osteolytic changes and who were matched to the study cohort for age and gender. Microbiological cultures, histopathologic examinations, and immunohistochemical analysis were performed on samples of periprosthetic tissue that were collected during revision arthroplasty on two hips with early osteolysis.
Results: The patients with early osteolysis had a significantly higher rate of hypersensitivity reaction to cobalt compared with controls (p = 0.031). The retrieved periprosthetic tissues showed no evidence of metallic staining, but histologic analysis revealed a perivascular accumulation of CD3-positive T-cells and CD68-positive macrophages and an absence of both particle-laden macrophages and polymorphonuclear cells. Immunohistochemical analysis demonstrated that bone-resorbing cytokines such as IL-1ß and TNF-a were produced mainly by infiltrating lymphocytes and activated macrophages.
Conclusions: These findings raise the possibility that early osteolysis in patients with this second-generation metal-on-metal hip replacement is associated with abnormalities consistent with delayed-type hypersensitivity to metal. A prospective study in which a large group of patients is evaluated with multiple diagnostic methods is needed in order to establish whether there is a causal relationship between metal hypersensitivity and osteolysis.

Level of E
http://abcmt.org/bones-metals.pdf

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology