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Suspected Metal Allergy and Femoral Loosening After Total Knee Arthroplasty: A Diagnostic Dilemma.

ABSTRACT: Metal sensitivity is increasingly prevalent and is associated with negative outcomes after total knee arthroplasty (TKA). Currently, there is no consensus on diagnostic criteria for TKA failure from immune reaction. We present a patient who had pain and aseptic effusion 2 years after TKA. Radiographs were concerning femoral loosening. Lymphocyte transformation testing showed nickel sensitivity. During revision surgery, the femoral component was loose. The histologic aseptic lymphocyte-dominated vasculitis-associated lesion score was 4 with elevated CD4+ lymphocytes, consistent with sensitization. Nickel-free revision implants were used. One year after surgery, the patient is symptom-free. This case has features suggestive of an immune reaction, with femoral loosening, and is illustrative of the diagnostic dilemma. Using a hypoallergenic knee eliminates future concern for nickel sensitivity.

SUBMITTER: Lieberman EG

PROVIDER: S-EPMC7818633 | biostudies-literature | 2021 Feb

REPOSITORIES: biostudies-literature

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Suspected Metal Allergy and Femoral Loosening After Total Knee Arthroplasty: A Diagnostic Dilemma.

Lieberman Elizabeth G EG Barrack Robert L RL Schmalzried Thomas P TP

Arthroplasty today 20210115

Metal sensitivity is increasingly prevalent and is associated with negative outcomes after total knee arthroplasty (TKA). Currently, there is no consensus on diagnostic criteria for TKA failure from immune reaction. We present a patient who had pain and aseptic effusion 2 years after TKA. Radiographs were concerning femoral loosening. Lymphocyte transformation testing showed nickel sensitivity. During revision surgery, the femoral component was loose. The histologic aseptic lymphocyte-dominated ...[more]

PMID: 33521207

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Project description:The ideal local anesthetic regime for femoral nerve block that balances analgesia with mobility after total knee arthroplasty (TKA) remains undefined.We compared two volumes and concentrations of a fixed dose of ropivacaine for continuous femoral nerve block after TKA to a single injection femoral nerve block with ropivacaine to determine (1) time to discharge readiness; (2) early pain scores and analgesic consumption; and (3) functional outcomes, including range of motion and WOMAC scores at the time of recovery.Ninety-nine patients were allocated to one of three continuous femoral nerve block groups for this randomized, placebo-controlled, double-blind trial: a high concentration group (ropivacaine 0.2% infusion), a low concentration group (ropivacaine 0.1% infusion), or a placebo infusion group (saline 0.9% infusion). Infusions were discontinued on postoperative Day (POD) 2. The primary outcome was time to discharge readiness. Secondary outcomes included opioid consumption, pain, and functional outcomes. Ninety-three patients completed the study protocol; the study was halted early because of unanticipated changes to pain protocols at the host institution, by which time only 61% of the required number of patients had been enrolled.With the numbers available, the mean time to discharge readiness was not different between groups (high concentration group, 62 hours [95% confidence interval [CI], 51-72 hours]; low concentration group, 73 hours [95% CI, 63-83 hours]; placebo infusion group 65 hours [95% CI, 56-75 hours]; p = 0.27). Patients in the low concentration group consumed significantly less morphine during the period of infusion (POD 1, high concentration group, 56 mg [95% CI, 42-70 mg]; low concentration group, 35 mg [95% CI, 27-43 mg]; placebo infusion group, 48 mg [95% CI, 38-59 mg], p = 0.02; POD 2, high concentration group, 50 mg [95% CI, 41-60 mg]; low concentration group, 33 mg [95% CI, 24-42 mg]; placebo infusion group, 39 mg [95% CI, 30-48 mg], p = 0.04); however, there were no important differences in pain scores or opioid-related side effects with the numbers available. Likewise, there were no important differences in functional outcomes between groups.Based on this study, which was terminated prematurely before the desired sample size could be achieved, we were unable to demonstrate that varying the concentration and volume of a fixed-dose ropivacaine infusion for continuous femoral nerve block influences time to discharge readiness when compared with a conventional single-injection femoral nerve block after TKA. A low concentration of ropivacaine infusion can reduce postoperative opioid consumption but without any important differences in pain scores, side effects, or functional outcomes. These pilot data may be used to inform the statistical power of future randomized trials.Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Dataset Information

Suspected Metal Allergy and Femoral Loosening After Total Knee Arthroplasty: A Diagnostic Dilemma.

Publications

Suspected Metal Allergy and Femoral Loosening After Total Knee Arthroplasty: A Diagnostic Dilemma.

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