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Total Knee Arthroplasty Failure Induced by Metal Hypersensitivity.

Gupta R, Phan D, Schwarzkopf R - Am J Case Rep (2015)

Bottom Line: We describe a 70-year-old patient who presented with persistent pain, swelling, and instability 2 years after a primary TKA.Serum cobalt was elevated and serum chromium was significantly elevated, while joint aspiration and inflammatory marker levels ruled out a periprosthetic infection.Revision TKA was performed, with intraoperative tissue pathology and postoperative leukocyte transformation testing confirming metal hypersensitivity as the cause for aseptic implant failure.

View Article: PubMed Central - PubMed

Affiliation: Joint Replacement Service, Department of Orthopaedic Surgery, University of California, Irvine, CA, USA.

ABSTRACT

Background: Metal hypersensitivity is an uncommon complication after total knee arthroplasty (TKA) that can lead to significant functional impairment and aseptic prosthesis failure.

Case report: We describe a 70-year-old patient who presented with persistent pain, swelling, and instability 2 years after a primary TKA. The patient had a history of metal hypersensitivity following bilateral metal-on-metal total hip arthroplasty (THA) that was revised to ceramic-on-polyethylene implants. Knee radiographs showed severe osteolysis with implant loosening. Serum cobalt was elevated and serum chromium was significantly elevated, while joint aspiration and inflammatory marker levels ruled out a periprosthetic infection. Revision TKA was performed, with intraoperative tissue pathology and postoperative leukocyte transformation testing confirming metal hypersensitivity as the cause for aseptic implant failure.

Conclusions: This case report demonstrates the clinical and laboratory signs that suggest metal hypersensitivity in total knee arthroplasty and the potential for joint function restoration with revision surgery.

No MeSH data available.


Related in: MedlinePlus

Intraoperatively at the revision surgery, there is significant synovitis surrounding the components, with the excised synovium appearing fibrous and inflamed.
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f4-amjcaserep-16-542: Intraoperatively at the revision surgery, there is significant synovitis surrounding the components, with the excised synovium appearing fibrous and inflamed.

Mentions: An incision was made through the previous scar, and a medial parapatellar approach was used to enter the joint. Upon arthrotomy through the previous incision, aggressive and hypertrophic fibrous synovitis was immediately identified around the joint (Figure 4). The synovial fluid appeared hazy and yellow. A complete synovectomy was performed and samples sent for histology analysis. Intraoperative joint fluid analysis resulted in 10% polymorphonucleocytes, 9% lymphocyte, 81% macrophage, and a leukocyte cell count of 533 cells/ml, with a very low likelihood of infection as the cause of failure. The tibial liner showed signs of mild wear. The femoral component was removed revealing severe bone loss and erosion, especially at the anterior femur and posterior femoral condyles, which were nearly completely resorbed. The lateral femoral epicondyle had a stress fracture line, most likely due to the weakened and resorbed bone leading to valgus collapse; this was seen after implant removal and was reduced and secured using a locking plate. The tibial component was completely loose and removed by hand, revealing again severe bone erosion and cyst formation. After the femur and tibia had been debrided to yield adequate bone stock, the revision TKA procedure was then completed using a varus-valgus constrained implant (Legion Total Knee System, Smith & Nephew, Memphis, Tennessee). Augments were utilized to reconstitute the anatomical joint line, achieve equal flexion and extension gaps, and ensure overall knee stability (Figure 5).


Total Knee Arthroplasty Failure Induced by Metal Hypersensitivity.

Gupta R, Phan D, Schwarzkopf R - Am J Case Rep (2015)

Intraoperatively at the revision surgery, there is significant synovitis surrounding the components, with the excised synovium appearing fibrous and inflamed.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4544332&req=5

f4-amjcaserep-16-542: Intraoperatively at the revision surgery, there is significant synovitis surrounding the components, with the excised synovium appearing fibrous and inflamed.
Mentions: An incision was made through the previous scar, and a medial parapatellar approach was used to enter the joint. Upon arthrotomy through the previous incision, aggressive and hypertrophic fibrous synovitis was immediately identified around the joint (Figure 4). The synovial fluid appeared hazy and yellow. A complete synovectomy was performed and samples sent for histology analysis. Intraoperative joint fluid analysis resulted in 10% polymorphonucleocytes, 9% lymphocyte, 81% macrophage, and a leukocyte cell count of 533 cells/ml, with a very low likelihood of infection as the cause of failure. The tibial liner showed signs of mild wear. The femoral component was removed revealing severe bone loss and erosion, especially at the anterior femur and posterior femoral condyles, which were nearly completely resorbed. The lateral femoral epicondyle had a stress fracture line, most likely due to the weakened and resorbed bone leading to valgus collapse; this was seen after implant removal and was reduced and secured using a locking plate. The tibial component was completely loose and removed by hand, revealing again severe bone erosion and cyst formation. After the femur and tibia had been debrided to yield adequate bone stock, the revision TKA procedure was then completed using a varus-valgus constrained implant (Legion Total Knee System, Smith & Nephew, Memphis, Tennessee). Augments were utilized to reconstitute the anatomical joint line, achieve equal flexion and extension gaps, and ensure overall knee stability (Figure 5).

Bottom Line: We describe a 70-year-old patient who presented with persistent pain, swelling, and instability 2 years after a primary TKA.Serum cobalt was elevated and serum chromium was significantly elevated, while joint aspiration and inflammatory marker levels ruled out a periprosthetic infection.Revision TKA was performed, with intraoperative tissue pathology and postoperative leukocyte transformation testing confirming metal hypersensitivity as the cause for aseptic implant failure.

View Article: PubMed Central - PubMed

Affiliation: Joint Replacement Service, Department of Orthopaedic Surgery, University of California, Irvine, CA, USA.

ABSTRACT

Background: Metal hypersensitivity is an uncommon complication after total knee arthroplasty (TKA) that can lead to significant functional impairment and aseptic prosthesis failure.

Case report: We describe a 70-year-old patient who presented with persistent pain, swelling, and instability 2 years after a primary TKA. The patient had a history of metal hypersensitivity following bilateral metal-on-metal total hip arthroplasty (THA) that was revised to ceramic-on-polyethylene implants. Knee radiographs showed severe osteolysis with implant loosening. Serum cobalt was elevated and serum chromium was significantly elevated, while joint aspiration and inflammatory marker levels ruled out a periprosthetic infection. Revision TKA was performed, with intraoperative tissue pathology and postoperative leukocyte transformation testing confirming metal hypersensitivity as the cause for aseptic implant failure.

Conclusions: This case report demonstrates the clinical and laboratory signs that suggest metal hypersensitivity in total knee arthroplasty and the potential for joint function restoration with revision surgery.

No MeSH data available.


Related in: MedlinePlus