Metal allergy in patients with total hip replacement: A review

Third Department of Orthopaedics, First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, Guangdong Province, China.
The Journal of international medical research (Impact Factor: 1.44). 02/2013; 41(2). DOI: 10.1177/0300060513476583
Source: PubMed


Metal-on-metal prostheses are increasingly and widely used in total hip arthroplasty, and offer particular benefit to patients with osteoarthritis. Adverse effects related to the release of metal ions (such as cytotoxicity, genotoxicity, carcinogenicity and metal allergy) are common, however. The aims of this review article were to explore the relationship between corrosion products and implant-related hypersensitivity, define normal and toxic metal ion concentrations, and differentiate between allergy and infection in painful total hip replacement. The simultaneous presence of corrosion products and hypersensitivity-related tissue reactions indicates a relationship between the development of corrosion and implant-related hypersensitivity. There are no clear boundaries between normal and toxic metal ion concentrations. Several methods exist for the differential diagnosis of metal allergy and infection, including ultrasound-guided aspiration, patch testing and arthroscopic biopsy. More research is required to elucidate fully the relationship between metal articulations and allergy, and to determine the concentrations of metal ions that lead to harmful effects.

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    • "Various immune responses to degradation products from implant materials can compromise the longevity of joint replacement [1,2,18,19]. Wear debris from bearing surfaces are generated continuously and phagocytosed by different cell types in the periimplant area inducing proinflammatory cascade in the periprosthetic space leading to the activation of osteoclasts and suppression of osteoblasts which in turn result in periprosthetic osteolysis, a process known as aseptic loosening of implants [1,27,28]. "
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    ABSTRACT: Background The aim of the study was to examine the reactivity of peripheral human leukocytes to various metal ions prior and following hip replacement in order to investigate implant-induced metal sensitivity. Methods Three patient groups were set up: (1) individuals without implants and no history of metal allergy (7 cases), (2) individuals without implants and known history of metal allergy (7 cases), and (3) patients undergoing cementless hip replacement (40 cases). Blood samples were taken in groups 1 and 2 at three different occasions; in group 3, prior and 3, 6, 12, 24, and 36 months after surgery. Peripheral leukocytes were separated and left either untreated or challenged with Ti, NiCl2, CoCl2, CrCl3, and phytohemagglutinin. Cell proliferation, cytokine release, and leukocyte migration inhibition assays were performed. Metal-induced reactivity was considered when all three assays showed significant change. Skin patch tests were also carried out. Results Both skin patch tests and leukocyte functional tests were negative in group 1, and both were positive in group 2. In group 3, after 6 months, 12% of the patients showed reactivity to the tested metals except for NiCl2. Following the 36-month period, 18% of group three became sensitive to metals (including all the earlier 12%). In contrast, patch tests were negative at each time point in group 3. Conclusions Orthopedic implant material may induce metal reactivity after implantation in a manner where susceptibility is yet to be elucidated. Leukocyte triple assay technique might be a useful tool to test implant material-related sensitivity.
    Full-text · Article · May 2013 · Journal of Orthopaedic Surgery and Research
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    ABSTRACT: The cause of premature failure of retrieved Dynamic Compression Plate (DCP) assembly from a 45 years old male was investigated by visual examination, chemical analysis of surface deposits by atomic absorption spectroscopy and Energy Dispersive spectroscopy coupled in a SEM. The electrochemical behavior of DCP and Screws was also evaluated in simulated body fluid through corrosion potential, Potentiodynamic Tafel scan and cyclic polarization. The chemical composition of DCP was not in conformity with ASTM F138-03. The higher concentration of 'Ni' and 'Cr' ions release and presence of chloride ions within the corrosion zone confirmed the dissolution of passive film by the aggressiveness of body environment. The negative corrosion potential, 2 times higher corrosion rate and varying passive current density of DCP than screws in simulated body fluid confirmed the higher susceptibility towards pitting and crevice corrosion. The higher protection tendency and breakdown potential with low passive current density of screws were also in support to lower corrosion tendency than DCP. Crown Copyright
    No preview · Article · Dec 2013 · Engineering Failure Analysis
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    ABSTRACT: Purpose: A prospective study was conducted to detect whether a relationship exists between metal allergy and post-operative pain in total hip and knee arthroplasty patients. We postulated that to some extent a relationship does exist between them. Materials and methods: Patients who had undergone total hip and knee arthroplasty surgery because of hip and knee disease were included. The exclusion criteria were patients who were treated with immunosuppressor two weeks pre-operatively, skin conditions around the patch testing site, and other uncontrollable factors. Each patient agreed to patch testing for three days before surgery. Photographic images before patch testing, two and three days after patch testing were obtained to evaluate the final incidence of metal allergy. The patch tests contained 12 metal elements; chromium, cobalt, nickel, molybdenum, titanium, aluminium, vanadium, iron, manganese, tin, zirconium, and copper. Two independent observers evaluated the images. The results were divided into a non-metal allergy group and a metal allergy group. Pre-operative and postoperative VAS score, lymphocyte transforming test, and X-rays were collected to detect the relationship between metal allergy and post-operative pain following total hip and knee arthroplasty. Results: There were 96 patients who underwent pre-operative patch testing. The overall metal allergy rate was 51.1% (49/96) in our study. Nickel, cobalt, manganese, and tin were the most common allergic metal elements in our study. Nine inappropriate cases were excluded, and 87 patients were finally included in our study. There were 36 metal allergy and 26 non-metal allergy patients in the THA group, while 11 metal allergy and 14 non-metal allergy patients were found in the TKA group. We found no relationship existed between metal allergy and post-surgery pain in total hip and knee arthroplasty. Conclusion: Pain caused by metal allergy usually presents as persistent and recurrent pain. The white cell count, C-reactive protein, erythrocyte sedimentation rate and postoperative radiographs were not affected. Currently, patch testing and lymphocyte transforming tests are used for metal allergy diagnosis. We deemed that a relationship between post-surgery pain and metal allergy in total hip and knee patients may exist to some extent. Larger samples and longer follow-up time are essential for further study.
    No preview · Article · Jun 2014 · International Orthopaedics
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