Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
Users online: 2633  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page

Table of Contents 
Year : 2022  |  Volume : 67  |  Issue : 6  |  Page : 812-813
Cutaneous metal hypersensitivity syndrome in total knee arthroplasty with titanium-coated implant

From the Department of Dermatology, Venereology and Leprosy, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India

Date of Web Publication23-Feb-2023

Correspondence Address:
Shreya Singh
Department of Dermatology, Venereology and Leprosy, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_791_22

Rights and Permissions

How to cite this article:
Prasanna S, Rane M, Singh S, Kharkar V. Cutaneous metal hypersensitivity syndrome in total knee arthroplasty with titanium-coated implant. Indian J Dermatol 2022;67:812-3

How to cite this URL:
Prasanna S, Rane M, Singh S, Kharkar V. Cutaneous metal hypersensitivity syndrome in total knee arthroplasty with titanium-coated implant. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:812-3. Available from:


Metal hypersensitivity syndrome is a type IV hypersensitivity reaction against metal ions through skin contact, lung inhalation or artificial implants.[1] It is a rare cause of failure of total knee arthroplasty (TKA) seen with the conventional cobalt-chromium implant, which should be suspected when other causes of implant failure such as infection, trauma and aseptic loosening have been ruled out. Our patient, a 73-year-old male, presented with uncontrollable itching over the knees associated with a burning sensation for two weeks. On enquiry, he gave a history of right knee arthroplasty for osteoarthritis two months back, following which he was asymptomatic for one and a half months. The implant used for the procedure was a titanium-coated cobalt-chromium alloy. Three weeks ago, he developed swelling and pain in the operated knee joint, which was not associated with constitutional symptoms. One week later, he developed itching over the operated site, which progressed to involve the other knee in a span of two days. Cutaneous examination revealed bilaterally symmetrical erythematous lichenified plaques with scaling and crusting extending from mid-thighs till the upper half of legs [Figure 1]a. There was periprosthetic swelling with a limitation of range of motion in the right knee [Figure 1]b. Post-operative surgical site infection was ruled out by negative joint aspirate culture and C-reactive protein. A preliminary diagnosis of metal hypersensitivity syndrome was made and the patient was started on systemic steroids following which the joint swelling and cutaneous symptoms resolved dramatically within two weeks. After the resolution of his symptoms, a skin patch test was performed with constituent metals and polymethyl-methacrylate, which was positive for nickel, cobalt and chromium [Figure 2]a and [Figure 2]b. This corroborated with our initial diagnosis of metal hypersensitivity syndrome secondary to implant metal. He was symptom-free for the next one month; however, he had to subsequently undergo revision arthroplasty due to the aseptic loosening of the implant.
Figure 1: (a) Erythematous lichenified plaques with crusting and scaling over bilateral knees. (b) Periprosthetic swelling over right knee with overlying dermatitis

Click here to view
Figure 2: (a) Skin patch test: Well 3 (Titanium), Well 8 (Bone cement), Well 4 (Cobalt), Well 5 (Nickel), Well 10 (Chromium). (b) Patch test positive in Well 4 (Cobalt), 5 (Nickel), 10 (Chromium)

Click here to view

Metal hypersensitivity syndrome secondary to implant material is a T cell-mediated immune response directed against corroded metal ions, polymethyl-methacrylate or in some cases, against antibiotic coating over the implant.[2] Patients present with periprosthetic synovitis, associated with a burning pain component, joint stiffness and limited range of motion. Less frequently, cutaneous manifestation is seen in the form of localised/generalised dermatitis.[2] Although no standard battery of investigations has been advised, skin patch test, lymphocyte migration inhibition test and lymphocyte transformation test have been utilised.[3] Management of symptomatic cases involves nonsteroidal anti-inflammatory drugs (NSAIDs), topical or systemic steroids for dermatitis and physiotherapy for joint stiffness. However, definitive management involves revision surgery for replacement with a tolerable implant material such as oxidised zirconium or a coating of titanium nitrite over the conventional cobalt-chromium implant to prevent corrosion of metal ions.[2],[4],[5] The manifestation of this rare complication with the use of hypoallergenic implant material has been reported in this case.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Wang Y, Dai S. Structural basis of metal hypersensitivity. Immunol Res 2013;55:83-90.  Back to cited text no. 1
Akil S, Newman JM, Shah NV, Ahmed N, Deshmukh AJ, Maheshwari AV. Metal hypersensitivity in total hip and knee arthroplasty: Current concepts. J Clin Orthop Trauma 2018;9:3-6.  Back to cited text no. 2
Granchi D, Cenni E, Tigani D, Trisolino G, Baldini N, Giunti A. Sensitivity to implant materials in patients with total knee arthroplasties. Biomaterials 2008;29:1494-500.  Back to cited text no. 3
Mitchelson AJ, Wilson CJ, Mihalko WM, Grupp TM, Manning BT, Dennis DA, et al. Biomaterial hypersensitivity: Is it real? Supportive evidence and approach considerations for metal allergic patients following total knee arthroplasty. Biomed Res Int 2015;2015:137287.  Back to cited text no. 4
Thomsen M, Rozak M, Thomas P. Pain in a chromium-allergic patient with total knee arthroplasty: Disappearance of symptoms after revision with a special surface-coated TKA—A case report. Acta orthop 2011;82:386-8.  Back to cited text no. 5


  [Figure 1], [Figure 2]


Print this article  Email this article
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (1,057 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

    Article Figures

 Article Access Statistics
    PDF Downloaded7    
    Comments [Add]    

Recommend this journal