A case series of cementless revision total knee arthroplasty in patients with benzoyl peroxide allergy
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The contact allergens nickel, cobalt, and chromium are often discussed as possible triggers of allergic reactions to orthopedic implants. Additionally, acrylates and polymerization additives in bone cement (e.g., benzoyl peroxide (BPO)) have been implicated as triggers of eczema, wound healing disorders, and aseptic implant loosening. We report about six patients with aseptic loosening after total knee arthroplasty (TKA), who underwent revision surgery after testing positive for BPO hypersensitivity.
After clarification of possible other causes of implant failure, epicutaneous testing had been performed and the implants were replaced in a two-stage procedure with cementless, diaphyseal anchoring, hypoallergenic (TiNb-coated) revision endoprostheses.
Epicutaneous testing revealed a BPO allergy in all six patients and an additional nickel allergy in three of the six patients. There was no histopathological or microbiological evidence for a periprosthetic infection. The clinical follow-up showed a low level of pain with good function, a stable knee joint, and proper implant position. The Knee Society Score (KSS) with its subscales Knee Score and Functional Score improved post-operatively from 43 to 70 points and from 47.5 to 68.3 points, respectively. Two implant-specific complications occurred: femoral stress shielding two years post-operatively with no further need for action and aseptic loosening of the tibial stem with the need of revision three years post-operatively.
The regression of complaints after replacement with cementless and nickel-free revision implants suggests allergic implant intolerance. Implantation of a cementless, hypoallergenic endoprosthesis might, therefore, be a surgical treatment strategy in patients with evidence of allergies.
KeywordsAllergy Benzoyl peroxide Nickel Metal Bone cement Total knee arthroplasty Revision
Compliance with ethical standards
Conflict of interest
S. Gravius has received a speaker honorarium from Waldemar LINK GmbH and financial support from Waldemar LINK GmbH to participate at a surgery course. The other authors declare that they have no conflict of interest. No benefits have been or will be received from a commercial party related directly or indirectly to the subject matter of this article.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.
- 3.Thomas P, von der Helm C, Schopf C, Mazoochian F, Frommelt L, Gollwitzer H, Schneider J, Flaig M, Krenn V, Thomas B, Summer B (2015) Patients with intolerance reactions to total knee replacement: combined assessment of allergy diagnostics, periprosthetic histology, and peri-implant cytokine expression pattern. Biomed Res Int 2015:1–9. https://doi.org/10.1155/2015/910156 CrossRefGoogle Scholar
- 10.Klimek L (2015) Allergiediagnostik in der Praxis: Was der Hausarzt wissen sollte. Dtsch Aerzteblatt Online. https://doi.org/10.3238/PersPneumo.2015.10.02.03
- 11.Krenn V, Morawietz L, Kienapfel H, Ascherl R, Matziolis G, Hassenpflug J, Thomsen M, Thomas P, Huber M, Schuh C, Kendoff D, Baumhoer D, Krukemeyer MG, Perino G, Zustin J, Berger I, Rüther W, Poremba C, Gehrke T (2013) Revised consensus classification. Histopathological classification of diseases associated with joint endoprostheses. Z Rheumatol 72:383–392. https://doi.org/10.1007/s00393-012-1099-0 CrossRefPubMedGoogle Scholar
- 13.Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG (2011) New definition for periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clin Orthop 469:2992–2994. https://doi.org/10.1007/s11999-011-2102-9 CrossRefPubMedGoogle Scholar
- 16.Hischebeth GTR, Randau TM, Molitor E, Wimmer MD, Hoerauf A, Bekeredjian-Ding I, Gravius S (2016) Comparison of bacterial growth in sonication fluid cultures with periprosthetic membranes and with cultures of biopsies for diagnosing periprosthetic joint infection. Diagn Microbiol Infect Dis 84:112–115. https://doi.org/10.1016/j.diagmicrobio.2015.09.007 CrossRefPubMedGoogle Scholar
- 22.Bozic KJ, Kamath AF, Ong K, Lau E, Kurtz S, Chan V, Vail TP, Rubash H, Berry DJ (2015) Comparative epidemiology of revision arthroplasty: failed THA poses greater clinical and economic burdens than failed TKA. Clin Orthop Relat Res 473:2131–2138. https://doi.org/10.1007/s11999-014-4078-8 CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Uter W, Rämsch C, Aberer W, Ayala F, Balato A, Beliauskiene A, Fortina AB, Bircher A, Brasch J, Chowdhury MM (2009) The European baseline series in 10 European countries, 2005/2006–results of the European Surveillance System on Contact Allergies (ESSCA). Contact Dermatitis 61:31–38CrossRefGoogle Scholar
- 29.Eis D, Wolf U (2008) “Qualitätssicherung beim Lymphozytentransformationstest” – Addendum zum LTT-Papier der RKI-Kommission “Methoden und Qualitätssicherung in der Umweltmedizin”: Mitteilung der Kommission “Methoden und Qualitätssicherung in der Umweltmedizin”. Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz 51:1070–1076. https://doi.org/10.1007/s00103-008-0641-3 CrossRefGoogle Scholar
- 35.Natu S, Sidaginamale RP, Gandhi J, Langton DJ, Nargol AVF (2012) Adverse reactions to metal debris: histopathological features of periprosthetic soft tissue reactions seen in association with failed metal on metal hip arthroplasties. J Clin Pathol 65:409–418. https://doi.org/10.1136/jclinpath-2011-200398 CrossRefPubMedGoogle Scholar