Adverse Reaction to Zirconia in a Modern Total Hip Arthroplasty with Ceramic Head

Are Allergy-Induced Implant Failures Actually Hypersensitivity Reactions to Titanium? A Literature Review

PURPOSE

This literature review was performed to assess whether implant failures are associated with titanium allergy.

MATERIALS AND METHODS

An electronic search of the MEDLINE/PubMed, Cochrane Library, and Scopus databases up to April 2021 was conducted, and the obtained articles were independently assessed by two reviewers. Articles describing cases of implant failure in which the cause of implant failure was only identified as allergy were included.

RESULTS

Twelve studies were included. Eight studies identified Ti allergy by clinical examinations, of which four used patch tests, three used the lymphocyte transformation test (LTT)/memory lymphocyte immunostimulation assay (MELISA), and one used both tests. Nine studies reported cases of titanium hypersensitivity in combination with other systemic allergy-related disorders, with eight cases also showing positive results for Ni, Hg, Cr, and Co hypersensitivity. Ten papers reported the improvement of symptoms after the removal of the Ti implants and their replacement with zirconia implants, and two of these papers showed good results.

CONCLUSION

Cases of probable titanium allergy included those with true titanium allergies and those with a potentially different cause. However, the differentiation of these cases is difficult. Since no definitive method has been established for diagnosing titanium allergy, a comprehensive diagnosis based on the clinical course and clinical examination using a patch test/LTT/MELISA is necessary. Implant treatment should be performed with caution in patients with any preoperative allergies.

Interaction of Ceramic Implant Materials with Immune System

The immuno-compatibility of implant materials is a key issue for both initial and long-term implant integration. Ceramic implants have several advantages that make them highly promising for long-term medical solutions. These beneficial characteristics include such things as the material availability, possibility to manufacture various shapes and surface structures, osteo-inductivity and osteo-conductivity, low level of corrosion and general biocompatibility. The immuno-compatibility of an implant essentially depends on the interaction with local resident immune cells and, first of all, macrophages. However, in the case of ceramics, these interactions are insufficiently understood and require intensive experimental examinations. Our review summarizes the state of the art in variants of ceramic implants: mechanical properties, different chemical modifications of the basic material, surface structures and modifications, implant shapes and porosity. We collected the available information about the interaction of ceramics with the immune system and highlighted the studies that reported ceramic-specific local or systemic effects on the immune system. We disclosed the gaps in knowledge and outlined the perspectives for the identification to ceramic-specific interactions with the immune system using advanced quantitative technologies. We discussed the approaches for ceramic implant modification and pointed out the need for data integration using mathematic modelling of the multiple ceramic implant characteristics and their contribution for long-term implant bio- and immuno-compatibility.

A comprehensive summary of disease variants implicated in metal allergy

Allergic disease represents one of the most prominent global public health crises of the 21^st century. Although many different substances are known to produce hypersensitivity responses, metals constitute one of the major classes of allergens responsible for a disproportionately large segment of the total burden of disease associated with allergy. Some of the most prevalent forms of metal allergy - including allergic contact dermatitis - are well-recognized; however, to our knowledge, a comprehensive review of the many unique disease variants implicated in human cases of metal allergy is not available within the current scientific literature. Consequently, the main goal in composing this review was to (1) generate an up-to-date reference document containing this information to assist in the efforts of lab researchers, clinicians, regulatory toxicologists, industrial hygienists, and other scientists concerned with metal allergy and (2) identify knowledge gaps related to disease. Accordingly, an extensive review of the scientific literature was performed - from which, hundreds of publications describing cases of metal-specific allergic responses in human patients were identified, collected, and analyzed. The information obtained from these articles was then used to compile an exhaustive list of distinctive dermal/ocular, respiratory, gastrointestinal, and systemic hypersensitivity responses associated with metal allergy. Each of these disease variants is discussed briefly within this review, wherein specific metals implicated in each response type are identified, underlying immunological mechanisms are summarized, and major clinical presentations of each reaction are described.Abbreviations: ACD: allergic contact dermatitis, AHR: airway hyperreactivity, ASIA: autoimmune/ autoinflammatory syndrome induced by adjuvants, BAL: bronchoalveolar lavage, CBD: chronic beryllium disease, CTCL: cutaneous T-cell lymphoma, CTL: cytotoxic T-Lymphocyte, DRESS: drug reaction with eosinophilia and systemic symptoms, GERD: gastro-esophageal reflux disease, GI: gastrointestinal, GIP: giant cell interstitial pneumonia, GM-CSF: granulocyte macrophage-colony stimulating factor, HMLD: hard metal lung disease, HMW: high molecular weight, IBS: irritable bowel syndrome, Ig: immunoglobulin, IL: interleukin, LMW: low molecular weight, PAP: pulmonary alveolar proteinosis, PPE: personal protective equipment, PRR: pathogen recognition receptor, SLE: systemic lupus erythematosus, SNAS: systemic nickel allergy syndrome, Th: helper T-cell, UC: ulcerative colitis, UV: ultraviolet.