Alternative materials and solutions in total knee arthroplasty for patients with metal allergy
ABSTRACT The annual number of total knee replacement implantations is rising continuously. A progressive cutaneous hypersensitivity rate against metallic materials in the population has been registered which can lead to an increase of allergy-induced reactions associated with implant loosening in the future although the correlation with an allergic cutaneous sensitisation has not been proven in all cases. On apparent allergy against metallic implant components different alternative solutions to standard endoprostheses should be taken into account for primary implantation or revision of total knee replacement, for example the application of implant components without metallic elements (e.g. ceramics), the use of non-allergic metallic implants, such as titanium or ZrNb alloys, or potential allergy-inducing metallic materials after masking the implant surface using a suitable coating. In the case of primary or revision surgery most patients with metal allergy are treated with a Ti(Nb)N-coated knee implant made of cobalt-chrome or titanium alloys in our hospital. Within an international multi-centre study we are currently implanting a newly developed knee endoprosthesis system with a ceramic femoral component as an alternative.
- SourceAvailable from: Domenico Tigani
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ABSTRACT: Total knee arthroplasty can be considered as a reliable surgical procedure with a good long-term clinical result. However, implant failure due to particle induced aseptic loosening as well as the aspect of hypersensitivity to metal ions still remains an emerging issue. The purpose of this prospective international multi-centre study was to evaluate the clinical and radiological outcomes and the reliability of the unconstrained Multigen Plus Total Knee System with a new BIOLOX® delta ceramic femoral component. Cemented total knee arthroplasty was performed on 108 patients (110 knees) at seven hospitals in three countries. Clinical and radiological evaluations were performed preoperatively, and after 3, 12 and 24 months postoperatively using the HSS-, WOMAC-, SF-36-score and standardised X-rays. The mean preoperative HSS-Score amounted to 55.5 ± 11.5 points and improved significantly in all postoperative evaluations (85.7 ± 11.7 points at 24 months). Furthermore, improvements in WOMAC- and SF-36-score were evaluated as significant at all points of evaluation. Radiolucent lines around the femoral ceramic component at 24 months were found in four cases. Progression of radiolucent lines was not seen and no implant loosening was observed. During the 24 month follow-up eight patients underwent subsequent surgery due to reasons unrelated to the implant material. The observed clinical and radiological results are encouraging for a long-term survival of the ceramic femoral component. Therefore, ceramic implants could be a promising solution not only for patients with allergies against metallic implant materials, but also for the osteoarthritic knee joint. Long-term follow-up is necessary to draw conclusions regarding the superiority of the ceramic knee implants concerning in vivo wear and long-term survivorship.The Open Orthopaedics Journal 04/2012; 6:172-8. DOI:10.2174/1874325001206010172
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- "However, ceramic implants are characterized by a higher risk of brittle fracture and the demand for cement-free implant fixation has not been realized so far, particularly in connection with polyvalent sensitization to cement components. Therefore, the use of ceramic knee implants is still limited  . "
ABSTRACT: Hypersensitivity reactions to implant materials have become more important in total knee replacement (TKR). The purpose of this retrospective comparative study was to evaluate the clinical and radiological outcomes of unconstrained bicondylar total knee prostheses with and without anti-allergic titanium(niobium)nitrite (Ti(Nb)N) coating. Twenty-four patients (25 TKRs) underwent a preoperative clinical evaluation and then a postoperative evaluation after 26.2 months in the allergy group treated with coated implants (n=13 implants) and after 24.5 months in the control group treated with uncoated implants but identical geometry (n=12) using HSS, WOMAC and SF-36 scores. Radiological evaluations were performed using standard anterior-posterior (a.p.) and lateral X-rays. During follow-up two patients of the allergy group had to undergo revision surgery due to non-implant-related reasons. A comparative analysis of both study groups showed a significant difference in the HSS scores at both evaluation time points (MW test p≤0.050); these findings are remarkable since the control group had a significantly lower score preoperatively (54.0 vs 65.0 points) and a significantly higher score (82.5 vs 75.0 points) postoperatively. The preoperative and postoperative WOMAC and SF-36 scores were comparable in both groups (MW test p≥0.052), although the postoperative increase in the score for the allergy group was lower. The radiological results were comparable in both groups and were unlikely to influence the results. This clinical study demonstrates the restricted outcome in postoperative function and quality of life in the allergy group compared to the control group.The Open Orthopaedics Journal 10/2011; 5:354-60. DOI:10.2174/1874325001105010354
Article: Implantatallergien[Show abstract] [Hide abstract]
ABSTRACT: Eine wachsende Patientenzahl profitiert von Osteosynthesematerialien und gelenkersetzenden Prothesen. Bei Komplikationen stehen klassische Auslöser wie mechanische Ursachen oder Infekte im Vordergrund. Legierungsmetalle oder Knochenzementkomponenten könnten als potenzielle Kontaktallergieauslöser zu Implantatunverträglichkeit führen. Dementsprechend werden Ekzeme, gestörte Wund- oder Frakturheilungen, Ergüsse, Schmerzen, Bewegungseinschränkungen oder Lockerungen auch als Ausdruck einer Implantatallergie beschrieben. Im Gegensatz zu der hohen Metallallergieprävalenz in der Bevölkerung scheint die Implantatallergie selten zu sein. Die Diagnosekriterien einer Metallimplantatallergie sind unscharf, sodass einerseits Differenzialdiagnosen – speziell ein Infekt – ausgeschlossen werden müssen und andererseits eine Zusammenschau von Epikutantest und Histopathologie des periimplantären Gewebes erfolgen sollte. Auch wenn das Risiko der Entwicklung von Komplikationen nicht genau abschätzbar ist, wird derzeit bei bekannter Metallallergie die Verwendung von Titanosteosynthesematerialien empfohlen und von einer Metall-Metall-Gleitpaarung in der Hüftendoprothetik abgeraten. Sofern man bei der gewohnten Kobalt-Chrom- (CoCr-)Polyethylen-Gleitpaarung bleibt, sollte in einem gut dokumentierten Aufklärungsgespräch von dem metallallergischen Patienten die Zustimmung erlangt werden. An increasing number of patients receive and benefit from osteosynthesis materials or artificial joint replacement. The most common complications are mechanical problems or infection. Metals like nickel, chromium and cobalt as well as bone cement components like acrylates and gentamicin are potential contact allergens which can cause intolerance reactions to implants. Eczema, delayed wound/bone healing, recurrent effusions, pain and implant loosening all have been described as manifestation of implant allergy. In contrast to the high incidence of cutaneous metal allergy, allergies associated with implants are rare. Diagnosis of metal implant allergy is still difficult. Thus differential diagnoses – in particular infection – have to be excluded and a combined approach of allergologic diagnostics by patch test and histopathology of peri-implant tissue is recommended. It is still unknown which conditions induce allergic sensitization to implants or trigger peri-implant allergic reactions in the case of preexisting cutaneous metal allergy. Despite the risk of developing complications being unclear, titanium based osteosynthesis materials are recommended for metal allergic patients and the use of metal-metal couplings in arthroplasty is not recommended for such patients. If the regular CoCr-polyethylene articulation is employed, the patient should give informed written consent. SchlüsselwörterOsteosynthese-Endoprothese-Implantat-Allergie-Implantatallergien KeywordsOsteosynthesis-Endoprosthesis-Implant-Allergy-Implant allergiesDer Hautarzt 03/2010; 61(3):255-264. DOI:10.1007/s00105-009-1907-x · 0.54 Impact Factor