Complete recovery after removal of the offending implant. Mitchelson AJ, Wilson CJ, Mihalko WM, Grupp TM, Manning BT, Dennis DA, Goodman SB, Tzeng TH, Vasdev S, Saleh KJ. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. 2012;25(4):463. Google Scholar. PubMed Central  Is this possible, and could it be a cause of pain or irritation after surgery? Park YS, Moon YW, Lim SJ, Yang JM, Ahn G, Choi YL. 2008;37:75–88. The lymphocyte transformation test for the diagnosis of drug allergy: sensitivity and specificity. There are no scientific or expert agreements on whether metal hypersensitivity reactions cause joint morbidity or failure following implant, and thus there is also no agreement on which patients require pre-surgical allergy evaluation. Feb. 7–11. Metal hypersensitivity reactions to implants—opinions and practices of patch testing dermatologists. Major diagnostic criteria for post-implantation metal hypersensitivity reactions include : Eruption overlying the metal implant. Contact Dermatitis. Introduction: Metallic implants are integral to the practice of orthopedic surgery. Allergic dermatitis presumably due to metallic foreign bodies containing nickel or cobalt. Arthritis Care Res (Hoboken). Nam D, Li K, Riegler B, Barrack RL. Schalock PC, Menné T, Johansen J, Taylor JS, Maibach HI, Lidén C, Bruze M, Thyssen JP. Contact Dermatitis. Halpin DS. J Bone Joint Surg Br. This article is based on previously conducted studies, and does not involve any new studies of human or animal subjects performed by any of the authors. Leguy-Seguin V, Jolimoy G, Coudert B, Pernot C, et al. In some cases, it may be beneficial and indicated to use an appropriate allergen-free implant to eliminate patient worry as a potential source of post-operative pain in those reporting clinical metal reactions [44]. Neuro Endocrinol Lett. 1966;52:220–5. Sánchez Olivas MA, Valencia Zavala MP, Sánchez Olivas JA, Sepúlveda Velázquez G. Rev Alerg Mex. Skin exposure is not the same as the constant exposure experienced in the closed subcutaneous environment adjacent to the metallic implant. 2009;91:1252–62. Hypersensitivity reactions to orthopedic implanted materials exist but are rare. Cutaneous reactions to metal implants, orthopedic or otherwise, are well documented in the literature. While these studies are not supportive of pre-implant metal allergy evaluation, it is also still important to consider patient history of possible metal allergy when making an implant choice prior to surgery. Acta Orthop Scand. Clin Exp Dermatol. Middleton S, Toms A. Total hip and knee replacement surgery using metal alloy devices is common. - 149.28.141.51. Contact Dermatitis. Another study combined three in vitro assays, measuring different aspects of lymphocyte activation in the hope of improving diagnosis [80]. Allergic or hypersensitivity reactions to orthopaedic implants can pose diagnostic and therapeutic challenges. There is thus extensive literature on both sides that asserts or renounces a correlation between metal hypersensitivity reaction and metallic implant failure, which only serves to add to the existing confusion. The Rising Potential Impact of Metal Hypersensitivity An alternative approach uses clinical findings to identify those with a high suspicion of metal allergy who may benefit from metal allergy evaluation [77]. Luque I, Leyva L, Jose Torres M, Rosal M, Mayorga C, Segura JM, Blanca M, Juarez C. In vitro T-cell responses to beta-lactam drugs in immediate and nonimmediate allergic reactions. Zamzow H. Allergic reactions to knee prostheses from the viewpoint of a trauma surgeon of the “Medizinischer Dienst der Krankenversicherung”. Cramers M, Lucht U. 1990;72:126–30. 2005;87:1515–21. A cohort study of 127 patients with 161 TKA (56 patients with patch test positives) versus 161 matched control TKAs without known metal allergy history or positive patch testing were followed over a period of 5.3 years [41]. The total incidence of total shoulder arthroplasty has also been steadily increasing, to 27,000 in 2008 [3]. Catelas I, Lehoux EA, Hurda I, Baskey SJ, Gala L, Foster R, Kim PR, Beaulé PE. J Bone Joint Surg Am. A recent review lends support to the stance that pre-implantation testing is not routinely needed: the review acknowledged the presence of an association between implant failure and metal hypersensitivity, but concludes that the absence of a casual relationship means that the use of “hypoallergenic” implants cannot be justified [43]. Carlsson A, Möller H. Implantation of orthopaedic devices in patients with metal allergy. 1977;48:245–9. J Bone Joint Surg Am. Despite this, it is unlikely that the LTT will replace the patch test as the gold standard and most commonly clinically used test. proposed that pre-implantation screening prior to TKA is not necessary and that metal allergy post-TKA should only be diagnosed after all other possibilities are excluded [40]. Post-implantation testing is controversial and even positive LTT or patch test does not definitively diagnose morbidity from a metal allergy. J Bone Joint Surg Am. PubMed  Given that there is no clear conclusion on the link between metal allergy and implant failure, it logically follows that there is a similar lack of consensus on the approach to the testing and management of patients. In a separate study, patients receiving a metal TKA showed no increase in joint loosening in those with metal allergy prior to implant as determined by patch testing [42]. Cousen PJ, Gawkrodger DJ. It is challenging to predict who will have these reactions, even in those with established pre-implant metal allergy. Webley M, Kates A, Snaith ML. While uncommon, peri-implant metal allergic reactions may cause significant morbidity for the … However, patient-reported allergy was associated with decreased functional outcomes after TKA and poorer scoring of mental health after THA [44]. Ultimately, it is up to the patient and surgeon to decide the ‘best’ and most appropriate device. Metal sensitivity in patients treated for tibial fractures with plates of stainless steel. Münch HJ, Jacobsen SS, Olesen JT, Menné T, Søballe K, Johansen JD, Thyssen JP. Atanaskova Mesinkovska N, Tellez A, Molina L, Honari G, Sood A, Barsoum W, Taylor JS. Article  More research is needed to scientifically approach this issue. The dendritic cells present similar, but not the same. In the United States, approximately 5.2 million total knee replacements were performed from 2000 to 2010 [1] and these may double by 2020 [2]. Nautiyal VP, Mittal A, Agarwal A, Pandey A. Natl J Maxillofac Surg. Type IV allergic reactions to these implants occur, though infrequently. Bravo D, Wagner ER, Larson DR, Davis MP, Pagnano MW, Sierra RJ. 2016;27:241–7. With an aging population, clarifying the association between metal hypersensitivity reactions and implant failures bears enormous repercussions for health care costs, and avoids unnecessary morbidity in patients [24]. The crucial question at hand is whether there is a need to carry out screening prior to implanting metal devices. J Arthroplasty. Despite this, we believe several conclusions can be made: routine pre-implant testing in asymptomatic individuals is not indicated; listen to patient’s concerns about metal allergy if the concern arises; patch testing is probably the best pre- and post-implant screening test; post-implantation testing is controversial and even positive LTT or patch test does not definitively diagnose morbidity from a metal allergy; and complete recovery following revision placement of an immunologically inert device is diagnostic. At this time, the scientific literature clearly supports few conclusions. Lachiewicz PF, Watters TS, Jacobs JJ. This reluctance may in fact be correct, since the relationship between actual skin reactions in response to implanted metal allergy as well as peri-implant morbidity continues to be unclear [69]. Consequently, the possibility of being entangled in needless litigation provides a strong driving force for seeking clarification and consensus in the field. Early osteolysis following second-generation metal-on-metal hip replacement. © 2021 Springer Nature Switzerland AG. Thyssen JP, Menné T, Schalock PC, Taylor JS, Maibach HI. PubMed  Whereas dermal metal hypersensitivity is common, affecting 10% to 15% of the population, the immune reaction from implanted metals is much less common (< 0.1%), but has been associated with metal allergy and hypersensitivity producing a multitude of patient symptoms. Google Scholar. Teo, W.Z.W., Schalock, P.C. In general, allergic risk of titanium material is smaller than that of other metal materials. 2005;26:1019–26. Contact Dermatitis. Antony FC, Holden CA. Skin reactions caused by MHR include dermatitis reactions adjacent to and regionally adjacent to the implant site, generalized dermatitis, as well as erythema, generalized urticaria and cutaneous vasculitis. The discrimination between nickel-sensitive and non-nickel-sensitive subjects by an in vitro lymphocyte transformation test. Article  Br J Dermatol. While uncommon, peri-implant metal allergic reactions may cause significant morbidity for the affected individual—including aseptic loosening, pseudotumor formation and frank device failure. J Korean Med Sci. It is difficult to ascertain, using patch testing alone, if a patient truly does suffer from metal hypersensitivity, and idetermining which patient would benefit from implant removal/revision is also challenging. 2012;27(7):1276. Their general opinion is that there is not a relevant correlation between patch testing on the skin and the immunologic responses in and around the bone–implant interface [68]. Kim SH, Wise BL, Zhang Y, Szabo RM. Metal sensitivitity is the most common type of immune response to implants. Fisher AA. In another study of 50 patients following TKA, 32% had positive skin patch tests to the metal constituents of the device (n = 16), but there was no correlation between allergy and loosening or other prosthesis morbidity [42]. Merle C, Vigan M, Devred D, et al. J Bone Joint Surg. Most of these metal hypersensitivity (MHS) reactions are type IV/delayed-type hypersensitivity reactions. 2001;56:611–8. Association of psychological status and patient-reported physical outcome measures in joint arthroplasty: a lack of divergent validity. Other adverse reactions including device failure, chronic inflammation, pain, loosening of joint prostheses or re-stenosis of cardiac stents can also occur [20]. In Sweden, “virtually no such patients are evaluated” [53]. High rates of metal allergy amongst Nuss procedure patients dictate broader pre- operative testing. Counsell A, Heasley R, Arumilli B, Paul A. What about the management plan for patients with suspected metal hypersensitivity post-implantation? Bruze M. Thoughts on implants and contact allergy. Metal Hypersensitivity in Total Joint Arthroplasty. Benson MK, Goodwin PG, Brostoff J.
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