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World J Orthop. Feb 18, 2019; 10(2): 63-70
Published online Feb 18, 2019. doi: 10.5312/wjo.v10.i2.63
Allergy in total knee replacement surgery: Is it a real problem?
Maristella F Saccomanno, Giuseppe Sircana, Giulia Masci, Gianpiero Cazzato, Michela Florio, Luigi Capasso, Marco Passiatore, Giovanni Autore, Giulio Maccauro, Enrico Pola
Maristella F Saccomanno, Giuseppe Sircana, Giulia Masci, Gianpiero Cazzato, Michela Florio, Luigi Capasso, Marco Passiatore, Giovanni Autore, Giulio Maccauro, Enrico Pola, Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
Author contributions: All authors contributed equally to this paper with conception and design of the study, literature review and analysis, drafting, critical revision and editing of the manuscript, and in giving approval of the final version.
Conflict-of-interest statement: The authors have no conflicts of interest to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Enrico Pola, MD, PhD, Associate Professor, Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go Agostino Gemelli, 8, Rome 00168, Italy. enrico.pola@tiscali.it
Telephone: +39-06-30154326 Fax: +39-06-3051161
Received: October 7, 2018
Peer-review started: October 7, 2018
First decision: October 19, 2018
Revised: December 26, 2018
Accepted: January 5, 2019
Article in press: January 6, 2019
Published online: February 18, 2019
Abstract

Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.

Keywords: Knee arthroplasty, Total knee arthroplasty, Metal hypersensitivity, Metal allergy, Non-allergenic implants

Core tip: Metal hypersensitivity may be a cause of failure for total knee arthroplasty, although a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Patients with a clear history of metal allergy, must be carefully examined through dermatological and laboratory testing before surgery. However, despite the increase in cutaneous and systemic hypersensitivity reactions to metals, which raise concern about joint arthroplasties, allergies against implant materials remain quite rare and an unexplored issue.