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Dadkhahfar S, Chehrassan M, Faldini C. Hypersensitivity reactions to metals in spine surgery. Musculoskelet Surg 2023; 107:29-35. [PMID: 36344900 DOI: 10.1007/s12306-022-00765-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 10/05/2022] [Indexed: 11/09/2022]
Abstract
Hypersensitivity to orthopedic devices is a rare condition with an underestimated incidence due to the lack of diagnostic guideline and ambiguous clinical manifestations. Although hypersensitivity to metal is common, a few cases of hypersensitivity reactions have been reported after spinal instrumentation. Spinal fusion and stabilization require a wide range of devices such as screws, wires, bands, and artificial disk replacement devices. Spinal instrumented surgeries are different from total joint arthroplasty in several aspects such as degree and pattern of motion, loading environment, and adjacent tissues with distinct characteristics. The interval for hypersensitivity reactions to occur after spinal metallic implantation is usually weeks to months. The present review covers the topic of hypersensitivity reactions that have been reported after spinal surgeries with the focus on cutaneous presentations.
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Affiliation(s)
- S Dadkhahfar
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Chehrassan
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - C Faldini
- Istituto Orthopedico Rizzoli, Bologna, Italy
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Bogdanova-Bennett A, Sagi A, Asopa V, Field RE, Sochart DH. Nickel hypersensitivity and skin patch testing in total hip replacement surgery: a systematic review. EFORT Open Rev 2021; 6:825-838. [PMID: 34760283 PMCID: PMC8559563 DOI: 10.1302/2058-5241.6.210051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Approximately 60,000 cemented femoral stems are implanted in the UK each year with the majority being manufactured from stainless steel containing 10–15% nickel. Nickel hypersensitivity has been reported in up to 13% of the general population and there is a concern that nickel hypersensitivity might adversely affect the outcome of total hip replacement (THR). We reviewed the current literature on the potential link between nickel hypersensitivity and THR complications, and the usefulness of patch testing. We conducted a literature search in PubMed, MEDLINE and EMBASE databases. The level of evidence and the quality of the selected studies were assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the Methodological Index for Non-Randomised Studies tool, respectively. Twenty-six studies met the inclusion criteria, reporting on 1852 patients who underwent primary or revision THR. All studies detailed skin patch testing and recorded prevalence of nickel hypersensitivity from 1.5% to 33.3%. Five studies reported a rise in Nickel hypersensitivity following THR, while four reported a decreased prevalence post-operatively. Eight studies concluded that metal hypersensitivity could have developed following THR, while seven studies did not support a link between metal hypersensitivity and THR complications. Four of the studies recommended routine patch testing pre-operatively, but three others concluded that routine patch testing was not indicated. We have not identified a link between nickel hypersensitivity and THR complications, and the role of patch testing remains unclear. Further large-scale studies would be required to investigate this relationship and to clarify the role of patch testing in facilitating implant selection.
Cite this article: EFORT Open Rev 2021;6:825-838. DOI: 10.1302/2058-5241.6.210051
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Affiliation(s)
| | - Amit Sagi
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
| | - Vipin Asopa
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
| | - Richard E Field
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
| | - David H Sochart
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom, UK
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Mg and Its Alloys for Biomedical Applications: Exploring Corrosion and Its Interplay with Mechanical Failure. METALS 2017. [DOI: 10.3390/met7070252] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Teo WZW, Schalock PC. Metal Hypersensitivity Reactions to Orthopedic Implants. Dermatol Ther (Heidelb) 2017; 7:53-64. [PMID: 27995484 PMCID: PMC5336431 DOI: 10.1007/s13555-016-0162-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Indexed: 01/08/2023] Open
Abstract
Total hip and knee replacement surgery using metal alloy devices is common. Type IV allergic reactions to these implants occur, though infrequently. While uncommon, peri-implant metal allergic reactions may cause significant morbidity for the affected individual-including aseptic loosening, pseudotumor formation and frank device failure. It is challenging to predict who will have these reactions, even in those with established pre-implant metal allergy. At this time, the scientific literature clearly supports few conclusions. 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. More research is needed to scientifically approach this issue.
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Affiliation(s)
- Wendy Z W Teo
- Department of Surgery (Dermatology), Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Peter C Schalock
- Department of Surgery (Dermatology), Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
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Fage SW, Muris J, Jakobsen SS, Thyssen JP. Titanium: a review on exposure, release, penetration, allergy, epidemiology, and clinical reactivity. Contact Dermatitis 2016; 74:323-45. [PMID: 27027398 DOI: 10.1111/cod.12565] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 02/07/2016] [Accepted: 02/08/2016] [Indexed: 11/29/2022]
Abstract
Exposure to titanium (Ti) from implants and from personal care products as nanoparticles (NPs) is common. This article reviews exposure sources, ion release, skin penetration, allergenic effects, and diagnostic possibilities. We conclude that human exposure to Ti mainly derives from dental and medical implants, personal care products, and foods. Despite being considered to be highly biocompatible relative to other metals, Ti is released in the presence of biological fluids and tissue, especially under certain circumstances, which seem to be more likely with regard to dental implants. Although most of the studies reviewed have important limitations, Ti seems not to penetrate a competent skin barrier, either as pure Ti, alloy, or as Ti oxide NPs. However, there are some indications of Ti penetration through the oral mucosa. We conclude that patch testing with the available Ti preparations for detection of type IV hypersensitivity is currently inadequate for Ti. Although several other methods for contact allergy detection have been suggested, including lymphocyte stimulation tests, none has yet been generally accepted, and the diagnosis of Ti allergy is therefore still based primarily on clinical evaluation. Reports on clinical allergy and adverse events have rarely been published. Whether this is because of unawareness of possible adverse reactions to this specific metal, difficulties in detection methods, or the metal actually being relatively safe to use, is still unresolved.
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Affiliation(s)
- Simon W Fage
- Department of Dermato-Venereology, Aarhus University Hospital, 8000 Aarhus, Denmark
| | - Joris Muris
- Department of Dental Materials Science, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Gustav Mahlerlaan 3004, 1081 LA, Amsterdam, The Netherlands
| | - Stig S Jakobsen
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8000 Aarhus, Denmark
| | - Jacob P Thyssen
- National Allergy Research Centre, Department of Dermato-Allergology, Copenhagen University Hospital Herlev-Gentofte, 2900 Hellerup, Denmark
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Haughom BD, Erickson BJ, Hellman MD, Jacobs JJ. Reply to letter to the editor: do complication rates differ by gender after metal-on-metal hip resurfacing arthroplasty? A systematic review. Clin Orthop Relat Res 2015; 473:3983-4. [PMID: 26400250 PMCID: PMC4626477 DOI: 10.1007/s11999-015-4562-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/03/2015] [Indexed: 01/31/2023]
Affiliation(s)
- Bryan D. Haughom
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL USA ,Rush University Medical Center, 1611 W. Harrison St, Suite 200, Chicago, IL 60612 USA
| | - Brandon J. Erickson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL USA
| | - Michael D. Hellman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL USA
| | - Joshua J. Jacobs
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL USA
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Haughom BD, Erickson BJ, Hellman MD, Jacobs JJ. Do Complication Rates Differ by Gender After Metal-on-metal Hip Resurfacing Arthroplasty? A Systematic Review. Clin Orthop Relat Res 2015; 473:2521-9. [PMID: 25758375 PMCID: PMC4488218 DOI: 10.1007/s11999-015-4227-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although metal-on-metal (MoM) bearing surfaces provide low rates of volumetric wear and increased stability, evidence suggests that certain MoM hip arthroplasties have high rates of complication and failure. Some evidence indicates that women have higher rates of failure compared with men; however, the orthopaedic literature as a whole has poorly reported such complications stratified by gender. QUESTIONS/PURPOSES This systematic review aimed to: (1) compare the rate of adverse local tissue reaction (ALTR); (2) dislocation; (3) aseptic loosening; and (4) revision between men and women undergoing primary MoM hip resurfacing arthroplasty (HRA). METHODS Systematic MEDLINE and EMBASE searches identified all level I to III articles published in peer-reviewed journals, reporting on the outcomes of interest, for MoM HRA. Articles were limited to those with 2-year followup that reported outcomes by gender. Ten articles met inclusion criteria. Study quality was evaluated using the Modified Coleman Methodology Score; the overall quality was poor. Heterogeneity and bias were analyzed using a Mantel-Haenszel statistical method. RESULTS Women demonstrated an increased odds of developing ALTR (odds ratio [OR], 5.70 [2.71-11.98]; p<0.001), dislocation (OR, 3.04 [1.2-7.5], p=0.02), aseptic loosening (OR, 3.18 [2.21-4.58], p<0.001), and revision (OR, 2.50 [2.25-2.78], p<0.001) after primary MoM HRA. CONCLUSIONS A systematic review of the currently available literature reveals a higher rate of complications (ALTR, dislocation, aseptic loosening, and revision) after MoM HRA in women compared with men. Although femoral head size has been frequently implicated as a prime factor in the higher rate of complication in women, further research is necessary to specifically probe this relationship. Retrospective studies of data available (eg, registry data) should be undertaken, and moving forward studies should report outcomes by gender (particularly complications). LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Bryan D Haughom
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison Street, Suite 200, Chicago, IL, 60612, USA,
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Abstract
In a representative survey among members of the working group for joint replacement (AE) in Germany (86.7% response) it was found that 0.6% of patients with total knee arthroplasty (TKA) and 1.2% of patients with total hip arthroplasty (THA) may have a problem due to hypersensitivity to nickel or cobalt after implantation. Only one third of them may need revision surgery. Although patients with hypersensitivity are rare 84% of surgeons would prefer to use a specially coated allergy implant for knee arthroplasty patients. However, no long term results and few data on the topic of allergies and joint arthroplasty are available for these implants so that this has to be critically discussed with patients. Before a revision is performed it is recommended to perform knee arthroscopy to obtain tissue for microbiological and histopathological investigations. The second part of this questionnaire will look at the special question of how to deal with allergy patients based on constructed case examples.
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Systemic Toxicity and Hypersensitivity. Biomater Sci 2013. [DOI: 10.1016/b978-0-08-087780-8.00047-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Hallab NJ, Jacobs JJ. Orthopedic Applications. Biomater Sci 2013. [DOI: 10.1016/b978-0-08-087780-8.00073-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Granchi D, Cenni E, Giunti A, Baldini N. Metal hypersensitivity testing in patients undergoing joint replacement: a systematic review. ACTA ACUST UNITED AC 2012; 94:1126-34. [PMID: 22844057 DOI: 10.1302/0301-620x.94b8.28135] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
We report a systematic review and meta-analysis of the peer-reviewed literature focusing on metal sensitivity testing in patients undergoing total joint replacement (TJR). Our purpose was to assess the risk of developing metal hypersensitivity post-operatively and its relationship with outcome and to investigate the advantages of performing hypersensitivity testing. We undertook a comprehensive search of the citations quoted in PubMed and EMBASE: 22 articles (comprising 3634 patients) met the inclusion criteria. The frequency of positive tests increased after TJR, especially in patients with implant failure or a metal-on-metal coupling. The probability of developing a metal allergy was higher post-operatively (odds ratio (OR) 1.52 (95% confidence interval (CI) 1.06 to 2.31)), and the risk was further increased when failed implants were compared with stable TJRs (OR 2.76 (95% CI 1.14 to 6.70)). Hypersensitivity testing was not able to discriminate between stable and failed TJRs, as its predictive value was not statistically proven. However, it is generally thought that hypersensitivity testing should be performed in patients with a history of metal allergy and in failed TJRs, especially with metal-on-metal implants and when the cause of the loosening is doubtful.
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Affiliation(s)
- D Granchi
- Rizzoli Orthopaedic Institute, Laboratory for Orthopaedic Pathophysiology and Regenerative Medicine, Via di Barbiano 1/10, 40136 Bologna, Italy.
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Wang J, Tang J, Zhang P, Li Y, Wang J, Lai Y, Qin L. Surface modification of magnesium alloys developed for bioabsorbable orthopedic implants: a general review. J Biomed Mater Res B Appl Biomater 2012; 100:1691-701. [PMID: 22566412 DOI: 10.1002/jbm.b.32707] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 02/01/2012] [Accepted: 03/05/2012] [Indexed: 11/11/2022]
Abstract
As a bioabsorbable metal with mechanical properties close to bone, pure magnesium or its alloys have great potential to be developed as medical implants for clinical applications. However, great efforts should be made to avoid its fast degradation in vivo for orthopedic applications when used for fracture fixation. Therefore, how to decease degradation rate of pure magnesium or its alloys is one of the focuses in Research and Development (R&D) of medical implants. It has been recognized that surface modification is an effective method to prevent its initial degradation in vivo to maintain its desired mechanical strength. This article reviews the recent progress in surface modifications for prevention of fast degradation of magnesium or its alloys using in vitro testing model, a fast yet relevant model before moving towards time-consuming and expensive in vivo testing. Pros and cons of various surface modifications are also discussed for the goal to design available products to be applied in clinical trials.
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Affiliation(s)
- Jiali Wang
- Center for Translational Medicine Research and Development, Institute of Biomedical and Health Engineering, Chinese Academy of Sciences, Shenzhen, China.
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So S, Harris IA, Naylor JM, Adie S, Mittal R. Correlation between metal allergy and treatment outcomes after ankle fracture fixation. J Orthop Surg (Hong Kong) 2011; 19:309-13. [PMID: 22184160 DOI: 10.1177/230949901101900309] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To determine correlation between metal hypersensitivity and long-term foot and ankle function and pain after internal fixation using stainless steel implants. METHODS 60 men and 46 women (mean age, 47 years) who underwent internal fixation for ankle fractures completed a questionnaire 13 to 38 (mean, 26) months after surgery to assess their existing medical condition, history of metal hypersensitivity, problems and outcome of the implant (revision or removal), and the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle score. A subset of 12 men and 15 women then underwent patch testing for metal hypersensitivity to molybdenum, chromium, iron, manganese, and nickel. Patients with positive and negative reactions were compared. RESULTS 21 of the 106 patients underwent removal of the metal implants. The AAOS score was not associated with any of the variables, except for a history of metal hypersensitivity from dental implants and irritation around the surgical scar. Multiple linear regression analysis showed that only irritation around the surgical scar remained associated with poorer AAOS scores. Five of the 27 tested patients had a positive reaction. The mean AAOS scores did not differ significantly between patients with positive and negative reactions (34 vs. 31, p=0.73). Gender was not associated with the test results (p=0.63). None of the 5 patients with a positive reaction underwent revision surgery or reported any history of asthma or metal hypersensitivity. Of the 27 patients, one of the 8 who reported itching, irritation, redness or rash around the surgical scar had a positive reaction, compared to 4 of 19 patients who reported no such symptoms (p=1). Two of the 27 patients reported development of eczema after fixation, one of whom had a positive reaction. Only one of the 27 patients reported a history of metal hypersensitivity to jewellery, but had a negative reaction.. CONCLUSION Neither a history of metal hypersensitivity nor positive patch testing correlated with poor outcomes after internal fixation for ankle fractures using stainless steel implants.
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Affiliation(s)
- Sarah So
- South West Sydney Clinical School, University of New South Wales, Australia
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Cousen PJ, Gawkrodger DJ. Metal allergy and second-generation metal-on-metal arthroplasties. Contact Dermatitis 2011; 66:55-62. [DOI: 10.1111/j.1600-0536.2011.01970.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
STUDY DESIGN Case report. OBJECTIVE To review the management of a patient with progressive osteolysis of the vertebral body after undergoing cervical arthroplasty for management of a refractory radiculopathy. SUMMARY OF BACKGROUND DATA Since the Food and Drug Administration's (FDA) approval of cervical arthroplasty devices in 2007, many surgeons have incorporated this technology into clinical practice. As arthroplasty becomes more widespread, complications unique to this technology are inevitable. To date, only a limited number of complications have been reported in the literature suggesting the safety of this device. To the authors' knowledge, this report represents the first complication of osteolysis from a keel based arthroplasty device. METHODS A 30-year-old man underwent an uneventful C5-C6 total disc arthroplasty with initial benefit. Progressively worsening neck pain prompted repeat imaging at 9 and 15 months, which showed a progressive osteolytic process in the vicinity of the keel of the superior alloy endplate. This necessitated exploration of the surgical site, explantation of the implant and conversion of the disc arthroplasty to an arthrodesis. RESULTS Examination of the osteolytic area did not reveal any gross abnormalities. Testing of the device by the manufacturer did not reveal any defects. A comprehensive infectious workup was negative. The osteolytic process halted after the explantation of the device. A bony arthrodesis was achieved at 6 months and the patient remains symptom free 29 months after the initial procedure and 14 months after the revision. CONCLUSION This report illustrates an exceptional case of a progressive osteolysis with a keel based arthroplasty device. An immune mediated osteolytic process appears to be a plausible explanation for the clinical symptoms and radiographic progression seen in this case. Given the years of use of the ProDisc-C since its FDA approval in 2007, complications with this device are rare. This represents the first reported case of osteolysis from such an implant.
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Raison-Peyron N. Implants et prothèses (hors dentisterie) et allergie aux métaux. REVUE FRANCAISE D ALLERGOLOGIE 2010. [DOI: 10.1016/s1877-0320(10)70010-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hallab NJ, Caicedo M, Epstein R, McAllister K, Jacobs JJ. In vitro reactivity to implant metals demonstrates a person-dependent association with both T-cell and B-cell activation. J Biomed Mater Res A 2010; 92:667-82. [PMID: 19235773 PMCID: PMC2797558 DOI: 10.1002/jbm.a.32368] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hypersensitivity to metallic implants remains relatively unpredictable and poorly understood. We initially hypothesized that metal-induced lymphocyte proliferation responses to soluble metal challenge (ions) are mediated exclusively by early T-cell activation (not B-cells), typical of a delayed-type-hypersensitivity response. We tested this by comparing proliferation (6 days) of primary lymphocytes with early T-cell and B-cell activation (48 h) in three groups of subjects likely to demonstrate elevated metal reactivity: group 1 (n = 12) history of metal sensitivity with no implant; group 2a (n = 6) well performing metal-on-metal THRs, and group 2b (n = 20) subjects with poorly performing metal-on-polymer total joint arthroplasties (TJA). Group 1 showed 100% (12/12) metal reactivity (stimulation index > 2) to Ni. Groups 2a and 2b were 83% (5/6) and 75% (15/22) metal reactive (to Co, Cr, or Ni), respectively. Of the n = 32 metal-reactive subjects to Co, Cr, or Ni (SI > 2), n = 22/32 demonstrated >2-fold elevations in % of T-cell or B-cell activation (CD25+, CD69+) to metal challenge when compared with untreated control. 18/22 metal-activated subjects demonstrated an exclusively T-cell or B-cell activation response to metal challenge, where 6/18 demonstrated exclusively B-cell activation and 12/18 demonstrated a T-cell only response, as measured by surface activation markers CD25+ and CD69+. However, there was no direct correlation (R(2) < 0.1) between lymphocyte proliferation and % T-cell or B-cell activation (CD25+:CD69+). Proliferation assays (LTT) showed greater ability to detect metal reactivity than did subject-dependent results of flow-cytometry analysis of T-cell or B-cell activation. The high incidence of lymphocyte reactivity and activation indicate that more complex than initially hypothesized immune responses may contribute to the etiology of debris-induced osteolysis in metal-sensitive individuals.
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Affiliation(s)
- Nadim James Hallab
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois 60612, USA.
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Glyn-Jones S, Pandit H, Kwon YM, Doll H, Gill HS, Murray DW. Risk factors for inflammatory pseudotumour formation following hip resurfacing. ACTA ACUST UNITED AC 2009; 91:1566-74. [DOI: 10.1302/0301-620x.91b12.22287] [Citation(s) in RCA: 246] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Metal-on-metal hip resurfacing is commonly performed for osteoarthritis in young active patients. We have observed cystic or solid masses, which we have called inflammatory pseudotumours, arising around these devices. They may cause soft-tissue destruction with severe symptoms and a poor outcome after revision surgery. The aim of this study was to determine the incidence of and risk factors for pseudotumours that are serious enough to require revision surgery. Since 1999, 1419 metal-on-metal hip resurfacings have been implanted by our group in 1224 patients; 1.8% of the patients had a revision for pseudotumour. In this series the Kaplan-Meier cumulative revision rate for pseudotumour increased progressively with time. At eight years, in all patients, it was 4% (95% confidence interval (CI) 2.2 to 5.8). Factors significantly associated with an increase in revision rate were female gender (p < 0.001), age under 40 (p = 0.003), small components (p = 0.003), and dysplasia (p = 0.019), whereas implant type was not (p = 0.156). These factors were inter-related, however, and on fitting a Cox proportional hazard model only gender (p = 0.002) and age (p = 0.024) had a significant independent influence on revision rate; size nearly reached significance (p = 0.08). Subdividing the cohort according to significant factors, we found that the revision rate for pseudotumours in men was 0.5% (95% CI 0 to 1.1) at eight years wheras in women over 40 years old it was 6% (95% CI 2.3 to 10.1) at eight years and in women under 40 years it was 13.1% at six years (95% CI 0 to 27) (p < 0.001). We recommend that resurfacings are undertaken with caution in women, particularly those under 40 years of age but they remain a good option in young men. Further work is required to understand the aetiology of pseudotumours so that this complication can be avoided.
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Affiliation(s)
- S. Glyn-Jones
- Department of Orthopaedics, Nuffield Orthopaedic Centre Rheumatology and Musculoskeletal Sciences
| | - H. Pandit
- Department of Orthopaedics, Nuffield Orthopaedic Centre Rheumatology and Musculoskeletal Sciences
| | - Y.-M. Kwon
- Department of Orthopaedics, Nuffield Orthopaedic Centre Rheumatology and Musculoskeletal Sciences
| | - H. Doll
- Department of Public Health University of Oxford, Windmill Lane, Headington, Oxford OX3 7LD, UK
| | - H. S. Gill
- Department of Orthopaedics, Nuffield Orthopaedic Centre Rheumatology and Musculoskeletal Sciences
| | - D. W. Murray
- Department of Orthopaedics, Nuffield Orthopaedic Centre Rheumatology and Musculoskeletal Sciences
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Rau C, Thomas P, Thomsen M. [Metal sensitivity in patients with joint replacement arthroplasties before and after surgery]. DER ORTHOPADE 2009; 37:102-10. [PMID: 18210091 DOI: 10.1007/s00132-007-1186-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The object of the present study was to determine the incidence of metal sensitivity in patients with joint replacement arthroplasties before and after surgery and whether this is of significance as regards the final outcome of the operative procedure. A questionnaire-based survey involved 1,335 patients with an average age of 61 years and joint replacement arthroplasties before and after surgery. A history of dermal sensitivity to metal was given in 99 (7%) patients with almost equal frequency in the pre- and postoperative groups (7.6 vs 7.2%). In only 27 of 99 cases was the metal sensitivity recorded in the patient chart. In 46 cases investigation was done after knee or hip replacement arthroplasty with an average implant time in situ of 68 months. In 32 of 46 patients a sensitivity to the implanted material was known and they did not show any complications related to the metal sensitivity.It is currently unclear whether metal sensitivity could be induced by joint replacement arthroplasties and it remains uncertain whether loosening or infection causes the sensitization as a consequence of increased release of metal ions or vice versa. To draw further conclusions considerably more detailed studies involving more patients are clearly indicated.
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Affiliation(s)
- C Rau
- Abteilung Orthopädie I, Orthopädische Universitätsklinik, Heidelberg, Deutschland
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Morawietz L, Gehrke T, Schröder JH, Krenn V. [Histopathological diagnostics in endoprosthesis loosening]. DER PATHOLOGE 2007; 27:439-45. [PMID: 17041773 DOI: 10.1007/s00292-006-0867-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The implantation of total joint endoprostheses has become a routine procedure, being executed about 1.5 million times per year worldwide. The indications are osteoarthritis, rheumatic diseases, trauma and bone neoplasia. However, about 5-12% of patients develop pain and impaired function of the endoprosthesis within 10 years, necessitating revision surgery. During this operation, the so-called periprosthetic membrane between bone and prosthesis is removed. This connective tissue membrane has a pathogenetic impact on the loosening process and can be evaluated by histopathology. This article aims at elucidating the defined histomorphological criteria for the standardized diagnostics of periprosthetic membranes using a recently established classification system.
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Affiliation(s)
- L Morawietz
- Institut für Pathologie, Charité Universitätsmedizin, Berlin.
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25
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Montanaro L, Cervellati M, Campoccia D, Arciola CR. Promising in vitro performances of a new nickel-free stainless steel. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2006; 17:267-75. [PMID: 16555119 DOI: 10.1007/s10856-006-7313-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2004] [Accepted: 07/13/2005] [Indexed: 05/04/2023]
Abstract
Stainless steel is a metallic alloy largely employed in orthopaedics. However, the presence in its composition of a high quantity of nickel, an agent known to trigger toxic and allergic responses, is cause for concern. In this study, we have investigated the in vitro biocompatibility of a new nickel-reduced stainless steel, namely Böhler P558, in comparison to the conventional stainless steel AISI 316L. The neutral red (NR) uptake and the amido black (AB) tests were performed on L929 fibroblasts and MG63 osteoblasts to assess the cytotoxicity, while cytogenetic effects were evaluated on CHOK1 cells by studying the frequency of Sister Chromatid Exchanges (SCE) and chromosomal aberrations. Ames test was used to detect the mutagenic activity. The expression of selected markers typical of differentiated osteoblasts, such as alkaline phosphatase activity (ALP), type I collagen (CICP) and osteocalcin (OC) production, were also monitored in MG63 cells cultured on the tested materials. Our results indicate the absence of significant cytotoxicity and genotoxicity for both test alloys. ALP, CICP and OC analyses confirmed that both materials support the expression of these phenotypic markers. Overall, these data show that this Ni-free alloy possesses good in vitro biocompatibility and could have a potential for orthopaedic applications.
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Affiliation(s)
- Lucio Montanaro
- Research Unit on Implant Infections, Rizzoli Orthopaedic Institute, Bologna, Italy.
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26
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Abstract
Total joint replacement has evolved over the past 50 years from a concept that was first attempted in people suffering from osteoarthritis to a commonly applied practice in veterinary medicine. Although many questions have been answered, several controversies still exist, with many implant and technical options being explored. Currently, total hip and elbow replacement are commercially available options viable for use in dogs. These options are detailed in this article. Joint replacement for other canine joints (ie, knee, hock, shoulder) that develop osteoarthritis likely will be developed in the near future.
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Affiliation(s)
- Michael G Conzemius
- Department of Small Animal Surgery, College of Veterinary Medicine, Iowa State University, Ames, IA 50010, USA.
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27
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Montanaro L, Cervellati M, Campoccia D, Prati C, Breschi L, Arciola CR. No genotoxicity of a new nickel-free stainless steel. Int J Artif Organs 2005; 28:58-65. [PMID: 15742311 DOI: 10.1177/039139880502800110] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Stainless steel is a metallic alloy largely employed in orthopedics, maxillofacial surgery and orthodontic therapy. However, the presence in its composition of a high quantity of nickel, an agent known to trigger toxic, allergic and cancerogenous responses in humans, is cause of some concern. In this study, we have investigated the in vitro mutagenicity and genotoxicity of a new nickel-free stainless steel, namely P558, in comparison to the conventional stainless steel AISI 316L. The cytogenetic effects were evaluated by studying the frequency of Sister Chromatid Exchanges (SCE) and chromosomal aberrations. Ames test was performed to detect the mutagenic activity. Both P558 and AISI 316L did not cause any significant increase in the average number of SCE and in chromosomal aberrations, either with or without metabolic activation. Furthermore, the Ames test showed that the extracts of both P558 and of AISI 316L are not mutagenic. Overall, these findings prove that P558 is devoid of genotoxicity and mutagenicity. The present results, together with other previous interesting observations that P558 promotes osseointegration, suggest that this new nickel-free stainless steel can represent a better alternative to other conventional steel alloys.
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Affiliation(s)
- L Montanaro
- Research Laboratory on Biocompatibility of Implant Materials, Rizzoli Orthopedic Institute, Bologna, Italy.
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Affiliation(s)
- F C Antony
- Department of Dermatology and Orthopaedics, St. Helier Hospital, Surrey, UK.
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29
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Abstract
In-stent restenosis is a complication which impairs the success of coronary stenting. Recently, it was supposed that a delayed hypersensitivity reaction to nickel and molybdenum might be one of the triggering factors in in-stent restenosis. We have analyzed the data collected in our centre with respect to this hypothesis. Altogether, 34 patients were investigated (24 male, 10 female). Patch tests were performed with the standard series of the German Contact Dermatitis Research Group and a metal series containing the metal components of 316 L stainless steel. A positive patch test reaction to nickel was observed in 4 (11.8%) patients. None of the patients showed sensitization to the other metals. Retrospective analysis was performed in 20 patients: 2 of these patients had a positive patch test reaction to nickel, one of whom had an in-stent restenosis, and the other not. Restenoses were predominantly observed in patients with negative patch test reactions to nickel (6/18 patients). Out of the patients who were investigated prospectively only one showed sensitization to nickel. Restenosis was observed in 2 patients: neither patient had nickel allergy. Although it still cannot be excluded that metal allergy may play a role in the restenosis process in coronary stenting, there is at present little evidence for it.
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Affiliation(s)
- U Hillen
- Department of Dermatology, University of Essen, Germany.
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30
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