Preoperative Identification of a Bone–Cement Allergy in a Patient Undergoing Total Knee Arthroplasty
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The Journal of Arthroplasty Vol. 17 No. 6 2002 Case Report Preoperative Identification of a Bone–Cement Allergy in a Patient Undergoing Total Knee Arthroplasty Kevin Kaplan, BS,* Craig J. Della Valle, MD,* Kathleen Haines, MD,† and Joseph D. Zuckerman, MD* Abstract: Allergy to polymethyl methacrylate bone–cement or its components is unusual. Because of the potential for an inflammatory response in an allergic patient and the possibility of pain and loosening if a cemented implant is used, it is imperative to identify patients with this allergy to modify their treatment. We report the case of an otherwise healthy 60-year-old woman who needed a total knee arthroplasty and who had an allergy to methyl methacrylate bone–cement identified preoperatively. The appropriate evaluation for a patient who is suspected to have an allergy to bone–cement or its components is reviewed. Key words: allergy, bone– cement, knee, arthroplasty. Copyright 2002, Elsevier Science (USA). All rights reserved. Hypersensitivity reactions to the various compo- loosening if a cemented implant is used, it is imper- nents used in total joint arthroplasty, including ative to identify patients with this allergy to modify metallic components and bone–cement, have been their treatment. We report the case of an otherwise described [1–4]. Allergy to polymethyl methacry- healthy 60-year-old woman who needed a total late bone–cement or its components is unusual but knee arthroplasty and who had an allergy to methyl has been reported in several different settings, in- methacrylate bone–cement identified preopera- cluding dentistry, orthopaedic surgery, the printing tively. The appropriate evaluation of a patient who industry, and as a reaction to cosmetics [5–7]. Be- is suspected to have an allergy to bone–cement or cause of the potential for an inflammatory response its components is reviewed. in an allergic patient and the possibility of pain and Case Report From the Departments of *Orthopaedic Surgery and †Rheumatology, A 60-year-old woman presented with a 10-year New YorkUniversity–Hospital for Joint Diseases, New YorkCity, New York. history of progressively worsening right knee pain. Submitted October 30, 2001; accepted January 16, 2002. The patient described pain and a giving-way sensa- No benefits or funds were received in support of this study. tion of the right knee with a significant increase in Reprint requests: Joseph D. Zuckerman, MD, Department of Orthopaedic Surgery, 14th Floor, New York University–Hospital severity over the past year. Treatment provided by for Joint Diseases, 301 East 17th Street, New York City, NY her primary care physician included anti-inflamma- 10003. tory medications and hyaluronate injections, which Copyright 2002, Elsevier Science (USA). All rights reserved. 0883-5403/02/1706-0020$35.00/0 initially were effective, but her pain and disability doi:10.1054/arth.2002.33571 recurred. 788 Bone–Cement Allergy in TKA Patient • Kaplan et al. 789 Physical examination revealed an antalgic gait Haddad and Cobb et al [8] described 7 patients with with 5° varus alignment of the right knee. Tender- a history of rapid aseptic loosening of cemented ness was noted on patellar compression and over total hip arthroplasties who displayed a hypersen- the medial joint line with pain at the extremes of sitivity reaction to N,N-dimethylparatoluidine (an flexion. Range of motion was 0° to 105°. There was accelerator found in the liquid methacrylate mono- no significant collateral or cruciate ligament laxity. mer component of bone–cement). An allergy to 1 Radiographic examination showed advanced de- of the constituents of bone–cement may cause an generative arthritis with significant involvement of enhanced inflammatory reaction and accelerate the the medial and patellofemoral compartments. A process of aseptic loosening. Although there are few right total knee arthroplasty was indicated. long-termstudies in the literature reporting the Further history revealed that the patient had outcome of implantation in methyl methacrylate– experienced an allergy to artificial acrylic-based fin- allergic patients, we believe that cemented implan- gernails. She explained her hands were extremely tation in such patients places themat risk for a irritated and the nails were removed after a brief systemic inflammatory response (which may period. The patient also had experienced blisters in present in a variety of patterns [9]) and implant her mouth as a reaction to a temporary filling that failure resulting fromaseptic loosening. In the case was placed before the permanent filling. The pa- presented, the patient had a hypersensitivity to the tient’s dentist diagnosed her with an allergy to liquid methacrylate monomer (and polymerized methyl methacrylate. The patient reported no other bone–cement), although it is unclear to which known allergies to metals or to hair coloring. component of the monomer she was specifically To confirm the methyl methacrylate allergy, hypersensitive because direct testing of the various patch testing was done with a test panel of bone– monomer components was not done. cement components (Palacos Bone Cement; Bi- The currently accepted model of contact allergy omet, Warsaw, IN). This panel included 2% and 4% describes a delayed-type hypersensitivity reaction weight-to-weight mixtures of the liquid monomer that develops in a genetically susceptible individ- methyl methacrylate (also contains N,N-dimethyl- ual [9]. A hapten, such as N,N-dimethylparatoluid- p-toluidine, hydroquinone, and chlorophyll) in pet- ine, conjugates with a body protein, which creates a rolatum, methacrylate copolymer powder (also neoantigen capable of stimulating an immune re- contains di-benzoyl peroxide, zirconiumdioxide, sponse. This unique antigen is processed by den- and chlorophyll), a patch of solidified bone–ce- dritic cells or macrophages and presented to T cells, ment, and a control consisting of petroleum jelly. generating a cell-mediated, inflammatory re- On examination 72 hours later, erythema and in- sponse [9,10]. duration were noted in the areas exposed to the Acrylates, which are grouped under the more polymerized bone–cement and to the 2% and 4% generic name of acrylics, have a chemical structure mixtures of liquid monomer methyl methacrylate. allowing excellent adhesive capability. This material The methacrylate copolymer powder and control is used extensively in dental and orthopaedic pro- elicited no reaction. Because the patient reacted to cedures. Patients may come in contact with acrylics the liquid methacrylate monomer and to the poly- in cosmetics, paint, hearing aids, inks, surgical tape, merized bone–cement, we decided the use of a rubber stamp making, and various other materi- cemented total knee arthroplasty was contraindi- als [11–15]. A thorough patient history is likely to cated. uncover any exposure to these materials. In this The patient underwent a right total knee arthro- case, our patient described prior exposure to acrylic plasty using noncemented, porous ingrowth com- fingernails and acrylics in a temporary dental im- ponents. Her postoperative course was uneventful, plant, which enabled us to confirmthe allergy and and at 2 years postoperatively, the patient was modify her treatment. walking unlimited distances without assistive de- Contact dermatitis resulting from exposure to vices. Active range of flexion was 0° to 125°. She methyl methacrylate was reported in 1941 [16]. was able to do all of her activities of daily living. Several reports in the early 1970s involving derma- titis and loosening of the prosthesis alerted physi- cians to the possible role of a delayed-type hyper- Discussion sensitivity reaction to methyl methacrylate [17]. Monteny, Oleffe, and Donkerwolke [17] reported a Allergy to methyl methacrylate bone–cement or case of a 76-year-old patient with a cemented en- one of its components should be considered a con- doprosthesis who experienced an allergy to methyl traindication to the use of cemented implants. methacrylate monomer. Patch testing in this patient 790 The Journal of Arthroplasty Vol. 17 No. 6 September 2002 was strongly positive at several different concentra- Chemotechnique Diagnostics, Tygelsjo, Sweden) tions of methyl methacrylate monomer. These au- followed by placement of the antigens on the pa- thors hypothesized that methyl methacrylate tient’s back. The test site is examined at 72 hours to monomer, when pushed into the injured bone detect a delayed-type hypersensitivity reaction, blood vessels during implantation, acts as the aller- manifested by edema, erythema, and vesicles [9]. gen to which the patient mounts an immune re- An alternative method to conduct the patch test, as sponse. Monteny, Oleffe, and Donkerwolke et was used in our patient, involves formulating a 2% al [17] did not report the long-termfollow-up or weight-to-weight mix of diluted liquid methacry- treatment of this patient. late monomer, the methacrylate copolymer pow- Romaguera, Grimalt, and Vilaplana [18] reported der, and polymerized bone–cement each in petro- a case of a 31-year-old patient with a fracture of the latumand applying these to the skin. Further left femur who developed a deep infection after treatment of the patient should be based on con- surgery that was treated with methyl methacrylate clusions drawn fromthe history, physical examina- beads containing gentamicin. Fifteen days postop- tion, and results of the patch testing. eratively, an eczematous patch was found on the The literature does not definitively report the patient’s