Nickel allergy to orthopaedic implants: A review and case series

Treatment of failed cervical total disc replacements in a series of 53 cases and description of a management strategy

PURPOSE

To describe modes of failure of cervical TDR, their related treatment strategies, and to describe a management strategy for the treatment of failed cervical TDR.

METHODS

This retrospective study was based on a consecutive series of 53 cervical TDR patients who underwent removal or revision surgery. Chart review was conducted to collect general descriptive data, reasons for TDR removal/revision, duration from index implantation to re-operation, and the subsequent procedure performed.

RESULTS

Among 53 patients, 36 underwent TDR removal and fusion, 16 underwent TDR removal and replacement with another TDR, and one patient's TDR was revised by repositioning. The mean duration from index surgery to removal/revision was 40.1 months (range: 3 days-222 months). In all cases, removal/revision surgery was completed without complication. The most common reason for removal was severe osteolysis, often involving C. acnes infection, and was primarily associated with one implant type. TDR removal and fusion were performed for subsidence, device migration, treatment of symptoms arising from posterior anatomy (facet joints, etc.), approach-related complications and pain. TDR replacement was feasible for hypermobility, metal allergy, implant locked in kyphosis, and oversized implant use. In one case of TDR malpositioning, the device was successfully revised into appropriate position.

CONCLUSION

After cervical TDR failure, replacing a TDR with another implant can be feasible. Reasons for revision or removal after cervical TDR surgery include biomechanical failure, implant migration, surgeon or technical error, or biological reasons. The type of failure can help the surgeon create a strategy to address these complications.

Correlation between environmental nickel exposure and the development of arthritis: A large-sample cross-sectional investigation

BACKGROUND

Nickel is a common metallic element in orthopedic implanted devices and living environment exposures. It is associated with varieties of diseases. The purpose of this investigation was to explore the correlation between nickel exposure and the prevalence of arthritis.

METHODS

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) database from 2017 to 2018. Multivariate logistic regression was utilized to analyze the relationship between urinary nickel levels and arthritis. In addition, hierarchical modeling further explored the interactions and trends between urinary nickel levels and arthritis. Propensity score matching (PSM) method was used to reduce the effect of confounders. Additionally, restricted cubic spline curve (RCS) was used to assess the possible nonlinear association between urinary nickel and arthritis.

RESULTS

The investigation was comprised of 139 arthritis patients and 547 healthy participants. After correction by PSM, there was a positive correlation between arthritis and Nickel exposure levels. The risk of developing arthritis was significantly increased when nickel exposure levels were in the Q4 interval (OR=2.25, 95 % CI=1.03-5.02). When stratified by age and sex, nickel exposure was significantly and positively associated with arthritis in the subgroup aged over 65 years. (OR=2.78,95 %CI=1.20-6.46). Also, the difference between nickel exposure and arthritis was significant in the different gender subgroups (interaction P<0.05). Restricted cubic spline (RCS) results showed a significant linear association between nickel exposure levels and arthritis. In addition, there was a non-linear association between nickel exposure and arthritis across gender and age subgroups.

CONCLUSION

A significant positive association between nickel exposure levels and arthritis was showed by the experimental data. Controlling the use of nickel-containing medical prostheses and reducing exposure to nickel-containing daily necessity could help to slow the onset of arthritis.

Hierarchical Surface Pattern on Ni-Free Ti-Based Bulk Metallic Glass to Control Cell Interactions

Ni-free Ti-based bulk metallic glasses (BMGs) are exciting materials for biomedical applications because of their outstanding biocompatibility and advantageous mechanical properties. The glassy nature of BMGs allows them to be shaped and patterned via thermoplastic forming (TPF). This work demonstrates the versatility of the TPF technique to create micro- and nano-patterns and hierarchical structures on Ti40Zr10Cu34Pd14Sn2 BMG. Particularly, a hierarchical structure fabricated by a two-step TPF process integrates 400 nm hexagonal close-packed protrusions on 2.5 µm square protuberances while preserving the advantageous mechanical properties from the as-cast material state. The correlations between thermal history, structure, and mechanical properties are explored. Regarding biocompatibility, Ti40Zr10Cu34Pd14Sn2 BMGs with four surface topographies (flat, micro-patterned, nano-patterned, and hierarchical-structured surfaces) are investigated using Saos-2 cell lines. Alamar Blue assay and live/dead analysis show that all tested surfaces have good cell proliferation and viability. Patterned surfaces are observed to promote the formation of longer filopodia on the edge of the cytoskeleton, leading to star-shaped and dendritic cell morphologies compared with the flat surface. In addition to potential implant applications, TPF-patterned Ti-BMGs enable a high level of order and design flexibility on the surface topography, expanding the available toolbox for studying cell behavior on rigid and ordered surfaces.

Surgical Safety Does Not Happen By Accident: Learning From Perioperative Near Miss Case Studies

Adverse surgical events cause negative patient health outcomes and harm that can often overshadow the safe and effective patient care provided daily by nurses as members of interprofessional healthcare teams. Near misses occur far more frequently than adverse events and are less visible to nurse leaders because patient harm is avoided due to chance, prevention, or mitigation. However, near misses have comparable root causes to adverse events and exhibit the same underlying patterns of failure. Reviewing near misses provides nurses with learning opportunities to identify patient care weaknesses and build appropriate solutions to enhance care. As the operating room is one of the most complex work settings in healthcare, identifying potential weaknesses or sources for errors is vital to reduce healthcare-associated risks for patients and staff. The purpose of this manuscript is to educate, inform, and stimulate critical thinking by discussing perioperative near miss case studies and the underlying factors that lead to errors. Our authors discuss 15 near miss case studies occurring across the perioperative patient experience of care and discuss barriers to near miss reporting. Nurse leaders can use our case studies to stimulate discussion among perioperative and perianesthesia nurses in their hospitals to inform comprehensive risk reduction programs.

Complications of operatively treated distal radial fractures

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications.Level of evidence: V.

Titanium nitride coating of pectus bar increases metal contamination after minimally-invasive repair of pectus excavatum

INTRODUCTION

Previous studies demonstrated a release of toxic metals, e.g. nickel and chromium, from stainless steel bars used for minimally invasive repair of pectus excavatum (MIRPE). In the present study, we investigated the impact of titanium nitride coating on the metal release and exposure of MIRPE patients.

MATERIAL AND METHODS

We analyzed the courses of nickel and chromium levels in blood, urine and local tissue in patients undergoing MIRPE with a titanium nitride coated pectus bar between 03/2017 and 10/2018. Sample collection was scheduled prior to MIRPE, at defined postoperative time points and at bar removal. Additionally, we evaluated irritative symptoms. Results were compared to a control group who received uncoated stainless steel bars in a previous time period (03/2015-02/2017).

RESULTS

12 patients received coated pectus bars (mean age 15.7 years). The control group included 28 patients. After implantation of a titanium nitride coated bar, significant increase in systemic nickel and chromium levels after one, two and three years was noted. In an interim analysis one year after MIRPE, we observed patients with coated bars to have significantly elevated trace metal values compared to the control group. This elevation persisted throughout the observation period. Tissue metal values were also significantly increased. Irritative symptoms occurred significantly more often in study patients compared to controls (50.0% vs. 14.3%).

CONCLUSIONS

Coating of pectus bars with titanium nitride failed to reduce metal contamination after MIRPE. Instead, it resulted in a significant increase of trace metal levels after MIRPE, compared to patients with stainless steel bars, which may be explained by wear of the coating and inter-component mobilization processes.

Nickel-related hypersensitivity reactions following endovascular interventions: A review of current evidence

INTRODUCTION

Nickel is a principal alloying agent in the production of vascular endoprostheses, despite persisting as the most habitually identified allergen. Variable nickel-related hypersensitivity manifestations following endovascular intervention were reported, challenging established paradigms in treatment and accuracy of prognostic assessments. The objective of this review is to critically evaluate current metrics to maximise patient-related outcomes.

METHODS

A literature review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 statement. Patients indicative of nickel hypersensitivity reaction following endovascular intervention were discerned. A positive reaction was defined by patch testing, histological analysis, or anamnesis indicative of nickel hypersensitivity. Morphology of implicating prostheses, adverse events and postoperative complications, clinical course, diagnostic and therapeutic strategies alongside patient prognosis were recorded.

RESULTS

Nickel-related hypersensitivity reactions following endovascular repair were identified in 36 patients with a median age of 44.5 years. 20 patients received nitinol-containing intervention. 28 (77.8%) patients are female. Multi-organ adverse reactions occurred in 21 (58.3%) patients with variable latency. 14 (38.9%) patients were presented with neurological adverse reactions manifesting mainly as unilateral hemiparesis. Dermatological reactions implicated 16 (44.4%) patients. Miscellaneous manifestations include suicidal ideation. 13 (36.1%) patients displayed previous metal intolerance and 32 (88.9%) patients had positive patch testing for nickel. Histological analysis of lesions and prostheses indicated lymphocytic infiltration. 5 (13.9%) patients experienced device-specific reactions as in-stent restenosis or auxiliary distal vessel stenosis. 11 (30.1%) patients received solely medical therapy and 5 (13.9%) patients received solely surgical therapy. 19 (52.7%) patients underwent both medical (oral corticosteroid) and surgical therapy (device retrieval). 26 (77.1%) patients achieved symptomatic cessation, 6 (16.7%) patients exhibited symptomatic persistence and 0 patients died.

CONCLUSION

Prophylactic pre-assessment for a history of metal allergy and consideration of prostheses alternatives is recommended to minimise reaction risk and severity. Despite nickel's predominant usage, information paucity urges additional studies to emphasise its implications and maximise patient outcomes.

Impact of dual neutralization of TNF-α and IL-1β along with Gentamicin treatment on the functions of blood and splenic neutrophils and its role on improvement of S. aureus induced septic arthritis

Researches of recent past years have emphasized potential of antibiotics to improve septic arthritis but as multi-drug resistant strains like MRSA are emerging fast, new alternative therapeutic advances are high in demand. This study aims to figure out the role of neutrophils in regulating inflammatory responses of S. aureus induced septic arthritis while using TNF-α Ab or IL-1β Ab along with antibiotic gentamicin or both in combination. In this study, role of anti-oxidant enzymes were investigated and correlated with generated ROS level. While expression of TLR2, TNFR2, MMP2, RANKL, SAPK/JNK in the spleen were evaluated through western blot. Serum activity of IL-8, IL-10, IL-12, OPG, OPN, CRP was assessed using ELISA. Flow cytometry study evaluated inflamed neutrophil population. Results have shown TNF-α neutralization along with gentamicin was able to reduce arthritic swelling prominently. While combination therapy effectively reduced blood neutrophil ROS activity, arginase activity, MPO activity along with spleen bacterial burden. Serum OPG, CRP, IL-10 level got reduced while serum OPN, IL-8 and IL-12 level enhanced in treatment groups, showing mitigation of inflammatory damage. Overall, it is a novel work that observed how antibiotic and antibody therapy enhanced neutrophil function positively to combat sepsis. This study may not be fully applicable in clinical trials as it is performed with animal model. Clinical trials include crystalline and inflammatory arthritides, trauma, neoplasm. Interdisciplinary collaboration between radiology, orthopaedic surgery and knowledge of animal system responses may give better idea to find proper therapeutic approach in future research works.

Bone Marrow Stem Cells with Tissue-Engineered Scaffolds for Large Bone Segmental Defects: A Systematic Review

Critical-sized bone defects (CSBDs) represent a significant clinical challenge, stimulating researchers to seek new methods for successful bone reconstruction. The aim of this systematic review is to assess whether bone marrow stem cells (BMSCs) combined with tissue-engineered scaffolds have demonstrated improved bone regeneration in the treatment of CSBD in large preclinical animal models. A search of electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) focused on in vivo large animal studies identified 10 articles according to the following inclusion criteria: (1) in vivo large animal models with segmental bone defects; (2) treatment with tissue-engineered scaffolds combined with BMSCs; (3) the presence of a control group; and (4) a minimum of a histological analysis outcome. Animal research: reporting of in Vivo Experiments guidelines were used for quality assessment, and Systematic Review Center for Laboratory animal Experimentation's risk of bias tool was used to define internal validity. The results demonstrated that tissue-engineered scaffolds, either from autografts or allografts, when combined with BMSCs provide improved bone mineralization and bone formation, including a critical role in the remodeling phase of bone healing. BMSC-seeded scaffolds showed improved biomechanical properties and microarchitecture properties of the regenerated bone when compared with untreated and scaffold-alone groups. This review highlights the efficacy of tissue engineering strategies for the repair of extensive bone defects in preclinical large-animal models. In particular, the use of mesenchymal stem cells, combined with bioscaffolds, seems to be a successful method in comparison to cell-free scaffolds.

NLRP3 inflammasome activation in response to metals

Implant surgery is followed by a series of inflammatory reactions that directly affect its postoperative results. The inflammasome plays a vital role in the inflammatory response by inducing pyroptosis and producing interleukin-1β, which plays a critical role in inflammation and tissue damage. Therefore, it is essential to study the activation of the inflammasome in the bone healing process after implant surgery. As metals are the primary implant materials, metal-induced local inflammatory reactions have received significant attention, and there has been more and more research on the activation of the NLRP3 (NOD-like receptor protein-3) inflammasome caused by these metals. In this review, we consolidate the basic knowledge on the NLRP3 inflammasome structures, the present knowledge on the mechanisms of NLRP3 inflammasome activation, and the studies of metal-induced NLRP3 inflammasome activation.

Rare Metallic Allergy Reaction Presentation to Cholecystectomy Surgical Clip

Metal allergies have been a growing concern in the general population over the past several decades. Laparoscopic cholecystectomy is the standard treatment for gallbladder diseases such as cholelithiasis and cholecystitis, during which surgical clips composed of metals such as nickel or titanium are often used to clamp the arteries and ducts. These metals are documented to produce hypersensitivity reactions. Here, we present the case of a 53-year-old male patient who successfully underwent laparoscopic cholecystectomy and two weeks later reported constant right upper quadrant pain accompanied by nausea that was exacerbated by exercise and food. After several months of severe interference with the patient's lifestyle, we removed the surgical clips after ruling out all possible organic causes of the pain. A total of six surgical clips were removed during surgery, and the patient reported a substantial resolution of symptoms post-operation. Post-cholecystectomy syndrome (PCS), allergy to the metallic surgical clips, and migration or improper clip placement during surgery were all considered possible causes for the pain. Still, the clinical presentation and laboratory studies pulled focus toward metallic surgical clip allergy as the most plausible cause for the presenting symptoms. The metallic haptens released by the surgical clips activate the innate and adaptive immune response cascades and pre-sensitize the CD8 and B cells to the metallic allergens. With reexposure, these pre-sensitized CD8 and B cells trigger a hypersensitivity reaction. Standardizing allergy tests as part of the pre-operation checklist can prove to be an inexpensive way to eliminate such post-surgical complications. Furthermore, alternatives like absorbable sutures or even different hypoallergenic metal or plastic clips can be considered viable options to replace nickel or titanium-made surgical clips during surgery.

Metal Allergy: State-of-the-Art Mechanisms, Biomarkers, Hypersensitivity to Implants

Metal allergy is mainly an environmental disorder which can cause allergic contact dermatitis. Environmental metal exposures include jewelry, everyday metal items, mobile phones, leather, metal-rich food and implants, including stents or anchors. While consumer exposure is liable for the majority of metal hypersensitivity cases, the significance of occupational exposure to metals remains relevant. Although the most common metal allergens are nickel, chromium, and cobalt; however, lately, gold, palladium, titanium, and some others have also attracted attention. This review highlights advances in metal allergy mechanisms, biomarkers for potential patients' stratification as well as biological treatments. The most recent evidence of human exposure to metal for risk assessment is discussed, as well as the relationship between the occurrence of metal hypersensitivity and implanted devices, including non-characteristic symptoms. The latest data on the diagnosis of metal hypersensitivity are also reported.

The effect of Nickel hypersensitivity on the outcome of total knee arthroplasty and the value of skin patch testing: a systematic review

Background

To assess the Nickel sensitizing potential of total knee arthroplasty (TKA), explore the relationship between hypersensitivity and clinical outcomes, and evaluate the utility of skin patch testing pre- and/or postoperatively.

Materials and methods

A literature search was performed through EMBASE, Medline and PubMed databases. Articles were screened independently by two investigators. The level of evidence of studies was assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the quality evaluated using the Methodological Index for Non-randomized Studies and Cochrane risk-of-bias tools.

Results

Twenty studies met the eligibility criteria, reporting on 1354 knee arthroplasties. Studies included patients undergoing primary or revision TKA, pre- and/or postoperatively, and used patch testing to identify Nickel hypersensitivity. Prevalence of Nickel hypersensitivity ranged from 0% to 87.5%. One study compared the prevalence of Nickel hypersensitivity in the same patient group before and after surgery and noted newly positive patch test reactions in three patients (4.2%). Three studies reported lower prevalence of Nickel hypersensitivity in postoperative patients compared to preoperative ones. Seven studies suggested that hypersensitivity might cause adverse clinical outcomes, but six did not support any relationship. Seven studies recommended preoperative patch testing in patients with history of metal allergy, and nine concluded that testing may be valuable postoperatively.

Conclusions

Patients undergoing TKA with no prior history of metal hypersensitivity do not seem to be at an increased risk of developing Nickel hypersensitivity, and there is conflicting evidence that patients with pre-existing hypersensitivity are more likely to experience adverse outcomes. Patch testing remains the most commonly used method for diagnosing hypersensitivity, and evidence suggests preoperative testing in patients with history of metal allergy to aid prosthesis selection, and postoperatively in patients with suspected hypersensitivity once common causes of implant failure have been excluded, since revision with hypoallergenic implants may alleviate symptoms.

Systems, Properties, Surface Modification and Applications of Biodegradable Magnesium-Based Alloys: A Review

In recent years, biodegradable magnesium (Mg) alloys have attracted the attention of many researchers due to their mechanical properties, excellent biocompatibility and unique biodegradability. Many Mg alloy implants have been successfully applied in clinical medicine, and they are considered to be promising biological materials. In this article, we review the latest research progress in biodegradable Mg alloys, including research on high-performance Mg alloys, bioactive coatings and actual or potential clinical applications of Mg alloys. Finally, we review the research and development direction of biodegradable Mg alloys. This article has a guiding significance for future development and application of high-performance biodegradable Mg alloys, promoting the future advancement of the magnesium alloy research field, especially in biomedicine.

Hypersensitivity Reaction Post Laparoscopic Cholecystectomy Due to Retained Titanium Clips

Titanium is an inert metal that has many medical uses and applications because of its biocompatibility. However, titanium is not completely devoid of adverse reactions. This was the case of a 55-year-old female who presented following a laparoscopic cholecystectomy with right upper quadrant pain, diarrhea, nausea and eventual neuralgia in the right lower extremity. This led to a series of diagnostic procedures including an esophagogastroduodenoscopy (EGD), a colonoscopy, a CT scan, and an abdominal ultrasound, all of which proved to be futile. The patient was eventually formally diagnosed with hypersensitivity reaction due to titanium clips and underwent a diagnostic laparoscopy, adhesiolysis, and removal of foreign body under fluoroscopy. A total of four clips were identified and removed during the procedure. Repeat x-ray showed no evidence of further clips in the right upper quadrant nor throughout the abdomen. The patient was discharged the same day and showed improvement of symptoms one week later during the post-operative follow-up visit.

Metallic Implants Used in Lumbar Interbody Fusion

Over the last decade, pedicle fixation systems have evolved and modifications in spinal fusion techniques have been developed to increase fusion rates and improve clinical outcomes after lumbar interbody fusion (LIF). Regarding materials used for screw and rod manufacturing, metals, especially titanium alloys, are the most popular resources. In the case of pedicle screws, that biomaterial can be also doped with hydroxyapatite, CaP, ECM, or tantalum. Other materials used for rod fabrication include cobalt-chromium alloys and nitinol (nickel-titanium alloy). In terms of mechanical properties, the ideal implant used in LIF should have high tensile and fatigue strength, Young's modulus similar to that of the bone, and should be 100% resistant to corrosion to avoid mechanical failures. On the other hand, a comprehensive understanding of cellular and molecular pathways is essential to identify preferable characteristics of implanted biomaterial to obtain fusion and avoid implant loosening. Implanted material elicits a biological response driven by immune cells at the site of insertion. These reactions are subdivided into innate (primary cellular response with no previous exposure) and adaptive (a specific type of reaction induced after earlier exposure to the antigen) and are responsible for wound healing, fusion, and also adverse reactions, i.e., hypersensitivity. The main purposes of this literature review are to summarize the physical and mechanical properties of metal alloys used for spinal instrumentation in LIF which include fatigue strength, Young's modulus, and corrosion resistance. Moreover, we also focused on describing biological response after their implantation into the human body. Our review paper is mainly focused on titanium, cobalt-chromium, nickel-titanium (nitinol), and stainless steel alloys.

Hypoallergenic unicompartmental knee arthroplasty and return to sport: comparison between Oxidized Zirconium and Titanium Niobium Nitride

BACKGROUND

The present study aims to compare the rate of return to sports in patients who underwent surgery for mobile-bearing UKA with either hypoallergenic TiNbN or with oxidized zirconium alloy implants.

METHODS

The records of two consecutive cohorts for a total of 90 hypoallergenic implants were prospectively analysed. The first cohort consisted of 41 consecutive series of medial mobile-bearing hypoallergenic TiNbN UKA, whereas the second cohort consisted of 49 consecutive medial fixed-bearing hypoallergenic Uni Oxinium.The clinical evaluation involved evaluating each patient's University of California, Los Angeles (UCLA) activity scoresand the High-Activity Arthroplasty Score(HAAS). Each patient was clinically evaluated on the day before surgery (T0), then after a minimum follow-up period of 12 months (T1), and finally after 24 months (T2).   Results:The only pre-operative difference between the two groups involved pre-operative BMI with significantly higher BMI in TiNbN Group (p<0.001). Both groups reported significant improvement at each follow-up compared with the previous and also at the final follow up with respect to UCLA and HAAS (p<0.05), except for UCLA in TiNbN between T1 and T2(p>0.05). Moreover, BMI improved significantly at the final follow up, but only in TiNbN group (p<0.05).

CONCLUSIONS

Both TiNbN and Oxinium UKA procedures enabled patients to return to an acceptable level of sports activity with excellent radiographic outcomes after the final follow up regardless of the age, gender, BMI, and bearing type.

Biologically modified implantation as therapeutic bioabsorbable materials for bone defect repair

For decades, researches have concentrated on the mechanical properties, biodegradation, and biocompatibility of implants used in the therapy of large size bone defect. In vivo studies demonstrate that bioabsorbable bone substitute materials can reduce the risk of common symptoms such as inflammation and osteonecrosis caused by bio-inert materials after long-term implantation. Several organic, inorganic, and composite materials have been approved for clinical application, based on their unique characteristics and advantages. Although some artificial bioabsorbable bone substitute materials have been used for years, there are still some disadvantages existing, such as low mechanical strength, high brittleness, and low degradation rate. Therefore, novel bioabsorbable composite materials biomaterials have been developed for bone defect repair. In this review, we provide an overview of the development of artificial bioabsorbable bone substitute materials and highlight the advantages and disadvantages. Furthermore, recent advances in bioabsorbable bone substitute materials used in bone defect repair are outlined. Finally, we discuss current challenges and further developments in the clinical application of bioabsorbable bone substitute materials.

Nickel hypersensitivity and skin patch testing in total hip replacement surgery: a systematic review

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

Return to physical activity and change in body mass index after hypoallergenic medial mobile-bearing unicompartmental knee arthroplasty

Background

The primary purpose of the present prospective study was to consecutively analyse the outcomes of the return to sports activity of patients with positive patch tests undergoing a medial mobile-bearing titanium niobium nitride (TiNbN) unicompartmental knee arthroplasty (UKA). The secondary purpose was to ascertain if a higher grade of physical activity leads to a reduction in the body mass index (BMI) of the patients.

Material and methods

Forty-one patients with positive skin patch tests were included in this prospective study. The clinical evaluation consisted of the University of California, Los Angeles (UCLA) activity scale and the High-Activity Arthroplasty Score (HAAS). Each patient was evaluated the day before surgery (T₀), after 12.37 ± 0.70 months (T₁), and on the day of the final follow-up, after 67.03 ± 18.2 months (T₂). Furthermore, the BMI of each patient was analysed before surgery and during the final follow-up.

Results

The UCLA and HAAS mean preoperative values ranged from 3.68 ± 1.1.7 and 6.15 ± 0.76 to 6.1 ± 0.76 and 10.34 ± 1.3, respectively, at T₁ (p < 0.0001) and to the final values of 6.34 ± 0.62 and 11.0 ± 8.9, respectively, at T₂ (UCLA: T₂ versus T₁: p = 0.132; T₂ versus T₀: p < 0.0001; HAAS: T₂ versus T₁: p = 0.0027; T₂ versus T₀: p < 0.001). BMI ranged from a preoperative value of 27.97 ± 3.63 to a final value of 26.84 ± 3.11 (p < 0.0001). The only differences within the subgroups concerned patients with BMI ≥ 28, showing a superior HAAS at each follow-up (p < 0.05). A positive correlation was found between BMI and HAAS at T₀ and T₂ (p < 0.05).

Conclusions

This is the first study to evaluate the rate of the return to sports activities and change in BMI following hypoallergenic UKA. The majority of patients reduced their weight following UKA and improved their physical activity, showing outcomes that were comparable to the standard cobalt–chrome (CoCr) prostheses, regardless of gender, age, BMI and implant size.

Level of evidence

IV – Prospective Cohort Study.

Trial registration researchregistry5978—Research Registry www.researchregistry.com

Supplementary Information

The online version contains supplementary material available at 10.1186/s10195-021-00598-4.

Diffuse Nickel Hypersensitivity Reaction Post-cholecystectomy in a Young Female

Nickel, a silvery-hard metallic element used in corrosion-resistant alloys, is widely used in the medical field. Nickel has aided in medical advancements; however, it has been known to cause hypersensitivity reactions. Retained foreign bodies due to surgical procedures may cause postoperative complications such as allergic reactions. This case involves a 30-year-old female presenting with non-specific symptoms involving multiple organ systems, notably with abdominal pain. Due to chronic symptoms, the patient was tested for metal allergies and diagnosed with hypersensitivity reactions to nickel surgical clips that were previously inserted during cholecystectomy. Subsequently, the patient had surgical removal of the foreign bodies, which led to significant improvement of her symptoms immediately. This case demonstrates a delayed hypersensitivity reaction to a foreign body involving multiple body systems and vague symptoms making the diagnosis challenging. It is important to carefully evaluate the patient's past medical history including history of any allergies. It also brings attention to the necessity of performing metal skin patch tests preoperatively for individuals with a history of any type of allergies.