Metal hypersensitivity in total joint arthroplasty

Objective: To review the clinical manifestations, testing methods, and treatment options for hypersensitivity reactions to total joint arthroplasty procedures. Data Sources: Studies were identified using MEDLINE and reference lists of key articles. Study Selections: Randomized controlled trials were selected when available. Systematic reviews and metaanalyses of peer-reviewed literature were included, as were case series and observational studies of clinical interest. Results: Total joint arthroplasty procedures are increasing, as are the hypersensitivity reactions to these implants. Evidence is not conclusive as to whether metal joint implants increase metal sensitivity or whether metal sensitivity leads to prosthesis failure. Currently, patch testing is still the most widely used method for determining metal hypersensitivity; however, there are no standardized commercial panels specific for total joint replacements available currently. In vitro testing has shown comparable results in some studies, but its use in the clinical setting may be limited by the cost and need for specialized laboratories. Hypersensitivity testing is generally recommended before surgery for patients with a reported history of metal sensitivity. In cases of metal hypersensitivity-related joint failure, surgical revision ultimately may be required. Knowledge about joint replacement hypersensitivity reactions becomes vital because the approach to the evaluation depends on appropriate testing to guide recommendations for future arthroplasty procedures. Conclusion: Evaluation of hypersensitivity reactions after total joint arthroplasty requires a systematic approach, including a careful history, targeted evaluation with skin testing, and in vitro studies.