Failure by Immune Reaction to Metal Debris in Total Joint Arthroplasty of Hip and Knee

Special Article- Knee Arthroplasty

Austin J Musculoskelet Disord. 2017; 4(1): 1038.

Failure by Immune Reaction to Metal Debris in Total Joint Arthroplasty of Hip and Knee

Boddu C1*, Nett MP2, Cushner FD3 and Scuderi GR4

1Clinical Fellow, NSLIJ Adult Reconstruction/Knee, Lenox hill hospital, USA

2Orthopedic Service Line, Northshore Long Island Jewish Health System, USA

3Chief of Orthopedics-Southside Hospital, USA

4Program Director, Orthopedic Service Line, USA

*Corresponding author: Chandrakanth Boddu, Clinical Fellow, NSLIJ Adult Reconstruction/Knee, Lenox hill hospital, USA

Received: November 03, 2016; Accepted: January 12, 2017; Published: January 13, 2017

Abstract

Background: We propose a clinical classification for Failure by Immune Reaction to Metal debris (FIRM) in Total Joint Arthroplasty (TJA) of hip and knee. We also developed an evidence based diagnostic scoring system and estimated the treatment threshold for FIRM.

Methods: Pub Med and Embase search engines were used to identify original articles. We classified FIRM and identified the individual diagnostic criteria for each type of FIRM. For each individual diagnostic criterion we estimated the pooled Diagnostic Odds Ratio (DOR+) and the individual discriminatory FIRM (id FIRM) scores. From these scores total discriminatory FIRM (TdFIRM) scores were calculated.

Results: We identified a total of 39 original articles for meta-analysis. Based on predominant symptom of clinical presentation, we classified FIRM in to two types i.e., FIRMtype1 and FIRMtype2. We identified 8 individual diagnostic criteria for FIRMtype1 and FIRMtype2 and for each type we estimated the pooled diagnostic odds ratio (DOR+) and the individual discriminatory FIRM (id FIRM) scores. TdFIRM score scores for FIRMtype1 and FIRMtype2 were 4.83 and 4.85 respectively. Treatment threshold for FIRMtype1 and FIRMtype2 were estimated to be 3.38 and 3.39 respectively.

Conclusion: This meta-analysis provides a clinically useful tool for decision making when evaluating a patient suspected to have developed clinical complication by immune reaction to metal debris from arthroplasty. Future studies on FIRM should utilize this scoring system in decision making and critically evaluate its validity.

Keywords: Total joint arthroplasty; Osteolysis; Failure by immune reaction to metal debris; Metal allergy; Metal hypersensitivity

Introduction

The terms metal allergy and metal hypersensitivity are used interchangeably in the current literature to describe a spectrum of complications caused by immune reaction to metal debris generated in total joint arthroplasty. At one end of the spectrum is dermatitis. The dermatitis caused by immune reaction to metal debris may be new in onset or exacerbation of previous lesions and, can be localized or generalized manifestation.

At the other end of the spectrum is a consequence of local immune reaction to metal debris generated by total joint arthroplasty presenting clinically as a variable combination of pain in the joint, cystic lesions around the joint, aseptic loosening of implants and instability of the joint. Various terminologies exist to describe histopathological and imaging findings in patients with pain in the joint suspected to be from local reaction to metal debris after total joint arthroplasty. Willert et al termed the histopathological findings in these patients as Aseptic Lymphocyte-dominated Vasculitis-Associated Lesion (ALVAL) and LymphocYte-Dominated Immunological Answer (LYDIA) [1]. Another histopathological term ‘Metallosis’ was used by Korovessis et al to describe similar findings [2]. Pandit et al used the term ‘Pseudotumour’ to describe cystic and solid masses associated with resurfacing devices [3]. Longton et al described an umbrella term Adverse Reaction to Metal Debris (ARMD) to describe clinical failures of hip joint arthroplasty presenting with pain, a large sterile effusion and/or macroscopic necrosis [4].

For the purpose of this study, we used the acronym ‘FIRM’ (Failure by Immune Reaction to Metal debris) to describe all the clinical failures of Total Joint Arthroplasty (TJA) in hip and also knee joint due to immune reaction to metal debris. The objectives of this study are twofold. One is to develop a classification system for FIRM in TJA of hip and knee that is based on distinctive clinical manifestations. Second is to develop a diagnostic scoring system to facilitate the clinician to make an accurate, evidence based diagnosis.

Materials and Methods

In January 2015, a Pub Med and Embase search was performed independently using two search terms ‘Metal Allergy Joint Replacement’ (method 1) and ‘Metal Hypersensitivity Joint Replacement’ (method 2) for record identification. The search term that yielded the maximum number of results among the two was used for records identification from that particular search engine. The duplicates among Pub Med and Embase search were identified and removed. The selected records were screened by reviewing the abstract for clinical data on TJA patients with FIRM and were included for full-text review. If abstract is not available for a record, it was selected for full-text review by default. Of all the records selected for full-text review, final analysis included only the articles with clinical data on TJA patients with FIRM who had a negative work-up for the possibility of infection or neoplasm (primary or metastatic) and could successfully be managed by removal of implants and reinsertion of new implants that generate no metal debris or by pseudoarthrosis (positive control). In addition, we looked carefully to identify such additional records which we may have missed during Pub Med or Embase search but have the data that we are interested in by reviewing the references section of all the full-text reviewed records and if such record is found, was included in the systematic review and meta analysis.

Part I: FIRM clinical classification

By systematic review of the articles selected for final analysis, we identified all the described complications due to FIRM in patients with TJA and grouped them depending on the most commonly observed patterns of clinical presentation.

Part II: FIRM diagnostic scoring system

A meta-analysis was performed to develop FIRM scoring system using the data from the full-text reviewed records. The first step was calculation of pooled diagnostic odds ratio (also called likelihood ratio) of all the individual diagnostic criteria for each defined type of FIRMtype 1 to n using the formula,

DOR+= (Most commonly observed result of a diagnostic criteria+0.5)/(Least commonly observed result of a diagnostic criteria+0.5).

Where, DOR+ is the pooled diagnostic odds ratio of a positive result. Addition of 0.5 to all counts is a validated statistical method to obtain a definable value of DOR+. Individual discriminatory FIRM score of each diagnostic criterion (idFIRMc1 to n) for FIRMtype 1 to n was derived by converting its linear DOR+ value in to logarithmic value.

If all the individual diagnostic criteria identified for FIRMtype 1 to n are perfectly independent of each other, the total discriminatory FIRM score of FIRMtype 1 to n that would determine the treatment threshold for revision surgery can be mathematically be expressed as,

tdFIRMtype 1 to n = idFIRMc1 + idFIRMc2 ……. + idFIRMcn

Where, tdFIRMtype 1 to n is the total discriminatory score of FIRMtype1 to n (in logarithmic scale), idFIRMc1 is the individual discriminatory FIRM score of a diagnostic criteria c1 for FIRMtype 1 to n (in logarithmic scale), and so on. If we found that the individual diagnostic criteria identified for FIRMtype 1 to n were partially independent of each other, we decided to fix the treatment threshold for revision surgery at 70% of the calculated tdFIRMtype1 to n for FIRMtype1 to n.

Results

When Pub Med and Embase were searched as per method 1 using the term ‘Metal Allergy Joint Replacement’ without applying any other filters, 195 and 76 articles were identified respectively. When a similar search was conducted as per method 2 using the term ‘Metal Hypersensitivity Joint Replacement’, 178 and 194 articles were identified in Pub Med and Embase respectively. The term that yielded maximum number of results among the two search terms was selected for record identification and abstract review. After removing the duplicates there were 334 articles available for screening of abstracts (Figure 1). When we included our unpublished record (MPN), we had a total of 335 records available for screening. We excluded 271 records among the final 335 that were screened, as they were not relevant to answer this study objective. We full text reviewed the remaining 68 records among the 335 records that were screened. Out of 68 records that were full text reviewed, 29 records were excluded for various reasons. Hence we identified a total of 39 original articles with data relevant to this study. During the process of full text review of these 39 records, we could not identify any additional original articles that were not previously identified by either Pub Med or Embase search but had the clinical data on FIRM in patients with TJA. Hence, we had a total of 39 articles available for meta-analysis.