Females with Unexplained Joint Pain Following Total Joint Arthroplasty Exhibit a Higher Rate and Severity of Hypersensitivity to Implant Metals Compared with Males: Implications of Sex-Based Bioreactivity Differences.

Abstract

Recent studies indicate that females demonstrate an increased risk of experiencing adverse local tissue reactions, aseptic loosening, and revision after primary metal-on-metal hip resurfacing arthroplasty compared with males; the underlying biological mechanisms responsible for sex discrepancies in implant failure remain unclear. In addition to anatomical and biomechanical sex differences, there may be inherent immunological disparities that predispose females to more aggressive adaptive immune reactivity to implant debris, i.e., metal sensitivity. In this retrospective study, we analyzed sex-associated rates and levels of metal sensitization in 1,038 male and 1,575 female subjects with idiopathic joint pain following total joint arthroplasty (TJA) who were referred for in vitro metal-sensitivity testing. Females demonstrated a significantly higher rate and severity of metal sensitization compared with males. The median lymphocyte stimulation index (SI) among males was 2.8 (mean, 5.4; 95% confidence interval [CI], 4.9 to 6.0) compared with 3.5 (mean, 8.2; 95% CI, 7.4 to 9.0) among females (p < 0.05). Forty-nine percent of females had an SI of ≥4 (reactive) compared with 38% of males, and the implant-related level of pain was also significantly (p < 0.0001) higher among females (mean, 6.8; 95% CI, 6.6 to 6.9) compared with males (mean, 6.1; 95% CI, 6.0 to 6.3). In a select group of patients who had joint pain following TJA and no evidence of infection and who were referred for metal-sensitivity testing, females exhibited a higher level of pain and demonstrated a higher rate and severity (as measured by lymphocyte SI) of metal sensitization compared with males. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.