Two-Stage Revision Total Knee Arthroplasty for Suspected Periprosthetic Joint Infection and Metal and Bone Cement Hypersensitivity

Main Article Content

Hassan Zmerly
Manuela Moscato
Vincenzo Mancuso
Valentina Di Gregori


Allergy, metal, bone cement, Periprosthetic joint infection, Revision total knee arthroplasty.


Hypersensitivity to implant components and periprosthetic joint infection should be detected before all revision arthroplasty, as misdiagnosis can lead to replacement loosening and the need for further revision procedures. We describe the case of a 69-year-old woman presenting a history of a painful cemented total knee replacement. Postoperative investigations showed loosening of X-ray components, suspected periprosthetic joint infection, and patch test hypersensitivity to nickel sulfate and methyl methacrylate. Two months later, a more specific patch test indicated non-allergy to the solid scratch of one bone cement. The patient underwent a two-stage revision with prosthesis removal and the temporary application of a specific cement spacer followed by the successful reimplantation of a cemented revision prosthesis. All candidates for the revision arthroplasty procedure must be investigated for hypersensitivity to metal and bone cement in order to avoid complications related to prosthesis intolerance and the need for further revision surgery; in the presence of hypersensitivity to bone cement and periprosthetic joint infection with a two-stage revision indication, the patient must be submitted to further patch tests with scratches of solid bone cement.
Abstract 824 | PDF Downloads 296 HTML Downloads 87 XML Downloads 0


1. Park CN, White PB, Meftah M, Ranawat AS, Ranawat CS. Diagnostic algorithm for residual pain after total knee arthroplasty. Orthopedics 2016;39:e246–52.

2. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: From the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 2011;469:2992–4.

3. Gupta R, Phan D, Schwarzkopf R. Total knee arthroplasty failure induced by metal hypersensi-tivity. Am J Case Rep 2015;16:542–7.

4. Saccomanno MF, Sircana G, Masci G, et al. Allergy in total knee replacement surgery: Is it a real problem? World J Orthop 2019;10(2):63–70.

5. Mortazavi SMJ, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty: Predictors of failure. Clin Orthop Relat Res 2011;469:3049–54.

6. Bloemke AD, Clarke HD. Prevalence of self-re-ported metal allergy in patients undergoing primary total knee arthroplasty. J Knee Surg 2015;28:243–6.

7. Kaplan K, Della Valle CJ, Haines K, Zuckerman JD. Preoperative identification of a bone-cement allergy in a patient undergoing total knee arthro-plasty. J Arthroplasty 2002;17:788–91.

8. Middleton S, Toms A. Allergy in total knee arthroplasty: A review of the facts. Bone Joint J 2016;98-B:437–41.

9. Faschingbauer M, Renner L, Boettner F. Allergy in total knee replacement. Does it exist?: Review article. HSS J 2017;13:12–9.

10. Schalock PC, Menné T, Johansen JD, et al. Hypersensitivity reactions to metallic implants -diagnostic algorithm and suggested patch test series for clinical use. Contact Dermatitis 2012;66:4–19.

11. Verma SB, Mody B, Gawkrodger DJ. Dermatitis on the knee following knee replacement: A  minority of cases show contact allergy to chromate, cobalt or nickel but a causal associa-tion is unproven. Contact Dermatitis 2006; 54:228–9.

12. Struelens B, Claes S, Bellemans J. Spacer-related problems in two-stage revision knee arthroplasty. Acta Orthop Belg 2013;79:422–6.

13. Silvestre A, Almeida F, Renovell P, Morante E,  López R. Revision of infected total knee arthroplasty: Two-stage reimplantation using an antibiotic-impregnated static spacer. Clin Orthop Surg 2013;5:180–7.

14. Webley M, Kates A, Snaith ML.Metal sensitivity in patients with a hinge arthroplasty of the knee. Ann Rheum Dis 1978;37:373–5.

15. Stathopoulos IP, Andrianopoulos N, Paschaloglou D, Tsarouchas I. Revision total knee arthroplasty due to bone cement and metal hypersensitivity. Arch Orthop Trauma Surg 2017;137:267–71.