Lohmann C H, Hameister R, Singh G
Department of Orthopaedic Surgery, Otto-von-Guericke University, 44, Leipziger Strasse, 39120 Magdeburg, Germany.
Department of Orthopaedic Surgery, Otto-von-Guericke University, 44, Leipziger Strasse, 39120 Magdeburg, Germany; Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, 4, Medical Drive, 117594, Singapore.
Orthop Traumatol Surg Res. 2017 Feb;103(1S):S75-S81. doi: 10.1016/j.otsr.2016.06.021. Epub 2016 Dec 30.
Hypersensitivity reactions to implants in orthopaedic and trauma surgery are a rare but devastating complication. They are considered as a delayed-type of hypersensitivity reaction (type IV), characterized by an antigen activation of sensitized T-lymphocytes releasing various cytokines and may result in osteoclast activation and bone resorption. Potential haptens are originated from metal alloys or bone-cement. A meta-analysis has confirmed a higher probability of developing a metal hypersensitivity postoperatively and noted a greater risk of failed replacements compared to stable implants. Hypersensitivity to implants may present with a variety of symptoms such as pain, joint effusion, delayed wound/bone healing, persistent secretion, allergic dermatitis (localized or systemic), clicking noises, loss of joint function, instability and failure of the implant. Various diagnostic options have been offered, including patch testing, metal alloy patch testing, histology, lymphocyte transformation test (LTT), memory lymphocyte immunostimulation assay (MELISA), leukocyte migration inhibition test (LIF) and lymphocyte activation test (LAT). No significant differences between in vivo and in vitro methods have been found. Due to unconvincing evidence for screening methods, predictive tests are not recommended for routine performance. Infectious aetiology always needs to be excluded. As there is a lack of evidence on large-scale studies with regards to the optimal treatment option, management currently relies on individual case-by-case decisions. Several options for patients with (suspected) metal-related hypersensitivity exist and may include materials based on ceramic, titanium or oxinium or modified surfaces. Promising results have been reported, but long-term experience is lacking. More large-scaled studies are needed in this context. In patients with bone-cement hypersensitivity, the component suspected for hypersensitivity should be avoided. The development of (predictive) biomarkers is considered as a major contribution for the future.
骨科和创伤手术中植入物的超敏反应是一种罕见但具有破坏性的并发症。它们被认为是迟发型超敏反应（IV型），其特征是致敏T淋巴细胞的抗原激活，释放各种细胞因子，并可能导致破骨细胞激活和骨吸收。潜在的半抗原源自金属合金或骨水泥。一项荟萃分析证实，术后发生金属超敏反应的可能性更高，并指出与稳定的植入物相比，置换失败的风险更大。植入物超敏反应可能表现为多种症状，如疼痛、关节积液、伤口/骨愈合延迟、持续分泌、过敏性皮炎（局部或全身性）、咔嗒声、关节功能丧失、不稳定和植入物失败。已经提供了各种诊断方法，包括斑贴试验、金属合金斑贴试验、组织学、淋巴细胞转化试验（LTT）、记忆淋巴细胞免疫刺激试验（MELISA）、白细胞迁移抑制试验（LIF）和淋巴细胞激活试验（LAT）。体内和体外方法之间未发现显著差异。由于筛查方法的证据不足，不建议常规进行预测性试验。始终需要排除感染性病因。由于缺乏关于最佳治疗方案的大规模研究证据，目前的管理依赖于个案决策。对于（疑似）与金属相关的超敏反应患者，有几种选择，可能包括基于陶瓷、钛或氧化锆的材料或改性表面。已经报道了一些有希望的结果，但缺乏长期经验。在这方面需要更多的大规模研究。对于骨水泥超敏反应患者，应避免使用疑似引起超敏反应的组件。（预测性）生物标志物的开发被认为是未来的一项重大贡献。
