First nickel and cement-free knee revision performed in Colorado Springs!

Some patients who have had total knee replacement find themselves dealing with pain and swelling, motion, and mobility issues. Statistically, studies show one-fifth of them experience pain, which may be caused by a sensitivity to nickel or allergy to cement typically used in total knee replacement surgeries.  

Although some people may be aware of their having a nickel allergy, having noted a skin redness from the metal touching their skin, as in the case of a watch, belt buckle or jewelry, an allergy to bone cement is more complex. Its major ingredient, methyl methacrylate, is found in some plastics and products used in hair and nail salons. 

Diagnosing such a sensitivity or allergy is complicated, and previous nickel and cement allergy patients were thought to affect one out of 100,000 patients. Dr. William Howarth, M.D., FAAOS, a board-certified orthopedic surgeon with CommonSpirit Orthopedic North Nevada, at 4925 N. Nevada Ave. in Colorado Springs, has said that he has 15 patients in his clinic who have been diagnosed with allergies.  

Dr. Howarth worked for years on finding a prosthetic that would help patients with a cement and/or nickel allergy. The first successful surgery was performed at St. Francis Hospital – Interquest in early September. One of the largest implant companies, Zimmer Biomet, produced the implant, which is available to all surgeons … at a lower cost! The manufacturer has recognized the importance of having nickel free revision surgery available.  

“The allergy risk of patients is much higher these days, as exposure is much more common,” said Dr. Howarth. “The ongoing work that we’ve done over the last few years has revealed how common these allergies are to the public. I’ve witnessed the pain and compromise it can cause patients from day-to-day.” 

Dr. Howarth believes patients who have had a total knee replacement and are in pain should know why … and allergy testing should be performed on every patient who experiences postoperative pain. 

“I think patients with pain after a total knee replacement should ask about testing if they haven’t been tested,” said Dr. Howarth. “I think this is a long way from being the standard of care without some long-term following up and some sort of preoperative testing.” 

Among the ways to test for nickel and methyl methacrylate in patients: skin and blood tests, and breakdown of compounds associated with both nickel and bone cement.  
 
“Allergy testing for these components can be difficult. Most allergists do not test for these specific products; they must be requested by the surgeon and specifically targeted by the allergy team,” said Dr. Howarth. “This testing is expensive, not usually covered by insurance, and diagnosis can take a while.”  

Revision relief 

In a traditional knee revision that uses cement, the surgeon can fill in defects that commonly occur with removal and replacement of a new knee. Cement can act as mortar filling in defects in bone that occur with the removal of old implants. In a cementless, nickel free revision, all the cement that was previously in the patient must be removed. Other techniques must be employed to fill in defects in the patient’s bone, like bone grafting. There must be bone to implant contact with this new implant to ensure it is successful and grows — or binds — to the bone.  

“With a cementless total knee revision, these implants have a soft metal that has a roughened surface and can attach to the bone,” said Dr. Howarth. “This surgical procedure requires the surgeon to maximize the patient’s bone contact with the bone as much as possible. The bone contact must be healthy. Oftentimes, when you do a revision, there are large defects in the bone, which must be addressed for the success of the implant.” 

The surgical technique and implant design when performing a nickel-free and cement-free knee revision is difficult, requiring newer implanting techniques and higher precision. The surgery is lengthier, and a restriction of motion will be necessary to ensure the growth of the implant. A total knee revision with the cementless implant has the potential for lots of complications.  

David Schwerin, a patient of Dr. Howarth, who lives in Steamboat Springs suffered constant knee pain due to allergies from his previous knee replacements for five years. He was the second person in the country to get a nickel- and cement-free prosthetic at St. Francis – Interquest Hospital a little over a month ago.  

“Mr. Schwerin’s revision was of a previously revised total knee and after removal of these implants and all the cement, a huge bone defect on both the tibia and femur were left. He had been dealing with pain and swelling ever since his last surgery, along with limitations on a day-to-day basis. This pain resulted in disuse osteopenia and weakened bone, which complicates the surgery even more,” said Dr. Howarth. “Once I removed David’s cemented implants, there was a large void on the tibia and femur. I had to fix that void with a rarely used technique of stacking tibial cones; a customized implant specifically for this patient. We are currently doing pathologic testing to see the reaction of the body and bone in relation to the patient’s allergy. 

Schwerin traveled more than 200 miles to have Dr. Howarth operate because “he’s a man of skill, is compassionate and really good at what he does.”  He feels the surgery was totally worth it, and understand the healing and rehabilitation process will take more time due to the procedure. That said, once fully recovered, he is ready to get back to skiing, hiking and biking … and is also considering a knee revision on his other knee once he fully recovers.  

“Despite these surgeries being extensive and extremely painful in the short-term, the early testing on patients has been remarkably successful as the swelling has improved rapidly and the pain has improved. I have seen patients immediately feel better once the old implant is removed and the bone cement is extracted,” said Dr. Howarth. “Imagine the reaction to something constantly irritating your body in your knee with unrelenting discomfort. This is very frustrating for patients. We are working to relieve that feeling for the future.” 

Exciting, welcoming news  

CommonSpiritHealth is doing more than just imagining providing hope to patients with a total knee replacement who are in pain.  

“This surgery is a testament to our commitment to our patients,” said Dr. Howarth. “CommonSpirit supports our community and provides the best possible care for our patients. I have worked for several years trying to get these implants approved and successfully implanted and am encouraged with early success. I feel blessed to be a part of this innovative solution to the future of medicine.” 

Treatment by CommonSpirit physicians is compassionate and inclusive. This builds and nurtures meaningful relationships with patients and inspires trust. Care at CommonSpirit is inspired by faith, driven by innovation, and powered by humanity. Learn more at CommonSpirit Health | Health Care in Colorado, Kansas & Utah.