Making Sense of Metal Allergy and Hypersensitivity to Metallic Implants in Relation to Hand Surgery

Metal hypersensitivity in trapeziometacarpal arthroplasty: A systematic pattern of progression

Metal hypersensitivity is a rare and often underestimated complication, as shown by the small number of published studies, particularly concerning the upper limbs and the hand. However, the increase in the annual number of trapeziometacarpal arthroplasties underlines the importance of better understanding of this problem. We performed a study based on data from the revision of trapeziometacarpal prostheses to assess the incidence of this complication and to define a sequence of radiological changes to detect metal hypersensitivity. This single-center retrospective study included 37 patients operated on between January 2014 and November 2023 for revision of trapeziometacarpal prosthesis. Ten (27%) had no clearly identified cause of failure. For these 10 patients, we analyzed clinical data and postoperative X-rays. In the 11 revision arthroplasties, 2 patients had no symptoms or radiographic signs suggestive of allergy. Six patients had a-posteriori diagnosis established by allergy testing, which also identified 2 additional patients, for a total of 8 patients (21% of the initial cohort). In these cases, there was systematic metaphyseal osteolysis of the first metacarpal between 15 days and 1 month after implantation. Clinically, most patients had an asymptomatic period of 2 weeks to 1 month before onset of symptoms and osteolysis, often accompanied by local inflammation. This study found a reproducible pattern of progression, characterized by the appearance of radiographic signs of osteolysis in the first month, followed by clinical deterioration. Although this course is strongly suggestive of a metal hypersensitivity, it is crucial not to exclude the possibility of an infectious cause, which should always be considered.

Metal hypersensitivity in foot & ankle orthopaedic surgery: A systematic review

Introduction

Metal hypersensitivity affects 10-15% of individuals. Orthopaedic implants contain various metals and, therefore, metal hypersensitivity may impact patient outcomes.

Purpose

We report a systematic review of the literature on metal hypersensitivity in patients undergoing foot and ankle (F&A) surgery. Our goal is to provide an overview presenting symptoms, diagnostic methods, treatment, and clinical outcomes.

Methods

A comprehensive literature search of Ovid MEDLINE and EMBASE was performed from its inception (01-Jan 1966) to 23-Nov 2021. MeSH search terms on F&A were used including orthopaedic surgeries, metal types, and hypersensitivity. All full-text, English, experimental and observational studies reporting on metal hypersensitivity in the context of foot and/or ankle surgeries using metallic orthopaedic devices were included. Article screening, critical appraisal, and data extraction was performed by two reviewers. Disagreements were resolved by a third reviewer.

Results

Fifteen studies were identified, reporting on 45 patients (18 male and 27 female). Median age was 58 years and mean follow-up was 20.8 months. 42 static and three arthroplasty implants were included. In total, 19 patients (42.2%) were diagnosed with metal hypersensitivity to a constituent of their implant, including two (4.4%) patients diagnosed without metal hypersensitivity testing. Twenty-six patients (57.8%) tested negative to their metal implant components. Of the 19 patients allergic to a constituent of their implant, 14 underwent hardware removal and improved. Four patients were asymptomatic and the last was symptomatic, but not revised. Of these, 23 patients retained their hardware (eight with skin reactions) and two symptomatic patients underwent hardware removal.

Conclusion

Metal hypersensitivity in the context of F&A surgery is not widely reported. It should be a differential diagnosis in patients who present with hypersensitivity-type symptoms once infection and mechanical failure are ruled out. This data informs a comprehensive algorithm for identifying and treating metal hypersensitivity in F&A patients.

Level of evidence

Level IV.

Metallosis Following Titanium Implant Use in the Hand: A Case Report and Review of Current Literature

Adverse reaction to metal debris (ARMD) consists of a spectrum of changes ranging from pure metallosis to aseptic lymphocytic vasculitis-associated lesion and granulomatous inflammation. Currently described ARMD cases are mainly limited to arthroplasty, typically total hip and knee arthroplasties in the lower limb and total wrist arthroplasty in the upper limb. Hypersensitivity to a metallic implant in fracture fixation is rare, and a severe form of metallosis has not been reported so far. In this paper, we present a case of ARMD occurring 10 years after the use of titanium implants for fracture fixation in the hand. Intra-operative findings, histopathological results, and a literature review on ARMD are also described.

Examination of colorectal cancer cases with metal allergy

PURPOSE

To report our initiatives and treatment results for patients with colorectal cancer with metal allergy.

METHODS

A total of 27 patients (2.6%) with a history of metal contact dermatitis were identified among 1027 patients who underwent curative resection of colorectal cancer from 2014 to 2020. The results of the patch test, perioperative results, and postoperative colonoscopy findings were also investigated.

RESULTS

The patch test for metal allergens and staples was performed in 21 patients (77.8%), and 13 of them (61.9%) tested positive for at least one metal allergen. Ni (38.1%), Co (28.6%), and Pd (19.0%) showed higher positive rates than other metals, and 1 patient (4.8%) tested positive for staples. Stapled anastomosis/suturing was performed as planned in 15 of 27 patients. In 10 patients, the anastomosis method was changed from stapled to hand-sewn according to the no-patch test results (60%), positivity for multiple metals (20%), positivity for staples (10%), and surgeon's judgment (10%). No complications and abnormal colonoscopy findings were found to be associated with stapled anastomosis/suturing.

CONCLUSION

The patch test is useful for selecting an optimal anastomosis method for patients with suspected metal allergy.

Immune response differences in degradable and non-degradable alloy implants

Alloy based implants have made a great impact in the clinic and in preclinical research. Immune responses are one of the major causes of failure of these implants in the clinic. Although the immune responses toward non-degradable alloy implants are well documented, there is a poor understanding of the immune responses against degradable alloy implants. Recently, there have been several reports suggesting that degradable implants may develop substantial immune responses. This phenomenon needs to be further studied in detail to make the case for the degradable implants to be utilized in clinics. Herein, we review these new recent reports suggesting the role of innate and potentially adaptive immune cells in inducing immune responses against degradable implants. First, we discussed immune responses to allergen components of non-degradable implants to give a better overview on differences in the immune response between non-degradable and degradable implants. Furthermore, we also provide potential areas of research that can be undertaken that may shed light on the local and global immune responses that are generated in response to degradable implants.

Proximal Femoral Bone Cyst After Single Screw Fixation for Slipped Capital Femoral Epiphysis: A Case Report

CASE

An 11-year-old female patient underwent bilateral in situ fixation for slipped capital femoral epiphyses using single, cannulated, stainless steel screws. She presented 12 years later with a large osteolytic lesion of the proximal femur, which only involved 1 side. Histological evaluation showed a foreign-body reaction and synovial lining. Infection was ruled out and dynamic hip screw stabilization, and bone grafting were performed. The bone graft healed, and the hardware was removed to prevent a similar reaction. In retrospect, postoperative radiographs at 7 weeks showed subtle osteolysis along the screw.

CONCLUSION

Intra-articular drilling, vertical screw placement into the posterior epiphysis, and the prominent screw head may have led to this unexpected complication.

Metal hypersensitivity screening among frontline healthcare workers-A descriptive study

AIMS AND OBJECTIVES

The study aims were to (a) assess allergy screening practices, (b) determine the awareness of metal hypersensitivity among frontline healthcare workers and (c) examine perceived barriers to implementing metal hypersensitivity screening into clinical practice.

BACKGROUND

Adverse device-related events, such as hypersensitivity to metals, are well documented in the literature. Hypersensitivity to metal is a type IV T-cell-mediated reaction that can occur after cardiac, orthopaedic, dental, gynaecological and neurosurgical procedures where a device with metal components is implanted into the body. Patients with hypersensitivity to metal are likely to experience delayed healing, implant failure and stent restenosis. Identifying patients with a history of metal hypersensitivity reaction could mitigate the risk of poor outcomes following device implant. Yet in clinical practice, healthcare workers do not routinely ask about the history of metal hypersensitivity when documenting allergies. The existing literature does not report why this is not included in allergy assessment.

DESIGN

Following the STROBE checklist, a cross-sectional, descriptive study was conducted.

METHODS

Frontline healthcare workers were recruited using professional contacts and social online media to complete an online questionnaire. Quantitative data were summarised descriptively while thematic analysis was used to examine barriers to implementation.

RESULTS

Three hundred forty-five participants from 14 countries completed the questionnaire, with the majority (187/54%) practicing in Canada, in general medicine and intensive care units. Ninety per cent of the participants did not routinely ask about metal hypersensitivity when evaluating allergy history. Of the respondents, 86% were unaware of the association between metal hypersensitivity and poor patient outcomes. After presented with the evidence, 81% indicated they were likely or very likely to incorporate the evidence into their clinical practice. Common themes about barriers to implementing were 'Standards of Practice', 'Knowledge' and 'Futility of Screening'.

CONCLUSION

The findings suggest lack of awareness as the main reason for not including metal in routine allergy assessment.

Long-term outcomes of metacarpal fractures surgically treated using bioabsorbable plates: a retrospective study

Background

Implants made from bioabsorbable unsintered hydroxyapatite and poly-L-lactate composites (u-HA/PLLA) are widely used in the oral, maxillofacial, and orthopedic fields. This study assess the long-term (> 5 years) outcomes of patients with metacarpal fractures who were surgically treated using bioabsorbable plates and screws (Super-Fixsorb MX40 mesh; Teijin Medical Technology, Osaka, Japan).

Methods

A retrospective analysis of six patients with eight metacarpal fractures treated with bioabsorbable plates was done. All patients were followed for more than 5 years post-surgery. The clinical outcomes were evaluated using Q-DASH scores and the grip strength (GS): opposite side ratio. The resorption status of implants was assessed on plain computed tomography (CT) scans at final follow-up appointments.

Results

The mean age of the patients at the time of surgery was 29.5 years (16–54), and the median follow-up period was 81.8 months (68–101). All fractures united without displacement after an average of 3.5 months, and there were no implant specific complications associated with the use of absorbable plates. The mean grip strength ratio was 85.1% (56.8–104.5). The mean Q-DASH scores of 11.36 points (0–34.09) was good in all but two patients. We also observed that it took more than 8 years for the plates to be absorbed completely.

Conclusions

This study demonstrates that the process of bioabsorption in metacarpal fractures might be completed in about 8 years, and the absorption speeds were different inside and outside of the bone. The bioabsorbable plates are more cost-effective than metallic implants. The potential for bioabsorbable plates to be used in various clinical procedures is promising.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03841-x.

Could a Titanium Ulnar Shortening Plate Trigger a Metal Allergy? A Case Report

Background  With the growing use of metallic implants, increased research has focused on metal hypersensitivity. The purpose of this case report is to describe a patient with a suspected metal allergy to a titanium plate and to review the literature behind this controversial topic. Case Description  A 45-year-old woman underwent ulnar shortening osteotomy for ulnocarpal abutment. One year later, the patient continued to have chronic pain at the site of the implant, with negative work-up for infection, hardware loosening, or failure. During hardware removal, intraoperative findings revealed titanium particle wear in the surrounding tissues, and subsequent allergy testing revealed a new diagnosis of nickel allergy. Following hardware removal, the patient had complete resolution of her symptoms at 3 months without any recurrence after 12 months from the date of surgery. Discussion  Metals are the most common cause of allergic contact dermatitis. With the increased use of metallic implants, it is no surprise that metal implant allergies have become a cause for concern. While there are multiple tests to try and diagnose a metal implant allergy, there is no gold standard, and results are often difficult to interpret. Physicians need to be cognizant of metal allergies with there often vague symptoms as we continue to search for more reliable and affordable testing. Clinical Relevance  Metal implant allergies can be difficult to diagnose. It is often a diagnosis of exclusion but requires a heightened sense of awareness in the face of a negative work-up with persistent symptoms.

Prospective study of five-year outcomes and postoperative complications after total temporomandibular joint replacement with two stock prosthetic systems

To evaluate and compare outcomes and complications associated with reconstruction of the temporomandibular joint (TMJ), we prospectively analysed the data of 70 patients who had their joints replaced with stock prostheses during the period 2004-14 and who had been followed up for five years. We used two types of stock prostheses: the metal-on-metal Christensen system (CS), and the ultra-high-molecular-weight-polyethylene-on-metal Biomet® system (BS). Data were collected at 3, 6, 12, 24, 36, 48, and 60 months postoperatively and compared with preoperative measurements. Five years after the replacement there was an increase in mean (SD) mouth opening from 2.0 (0.6) to 4.0 (0.5cm) (p=0.012) in the CS, and from 2.5 (1.0) cm to 4.1 (0.6) cm (p=0.018) in the BS. The mean (SD) reductions in visual analogue pain scores were from 6.9 (1.6) to 2.0 (1.4) (p=0.001) in the CS, and 6.5 (1.4) to 1.5 (1.1) (p=0.001) in the BS. There were no significant differences in improvements in mouth opening or reduction in pain between the two groups. However, there were differences in the number of implants that failed, which led to removal and replacement of 2/14 prostheses in the CS group and 3/77 in the BS group (p=0.06). The results supported the placement of stock prostheses, as evidenced by a low incidence of complications and adverse events, and a long-term improvement in function and reduction in pain in the TMJ. The BS group had significantly fewer prosthetic failures than the CS group.

Biological effects of metal degradation in hip arthroplasties

Metals and metal alloys are the most used materials in orthopedic implants. The focus is on total hip arthroplasty (THA) that, though well tolerated, may be associated with local and remote adverse effects in the medium-long term. This review aims to summarize data on the biological consequences of the metal implant degradation that have been attributed predominantly to metal-on-metal (MoM) THA. Local responses to metals consist of a broad clinical spectrum ranging from small asymptomatic tissue lesions to severe destruction of bone and soft tissues, which are designated as metallosis, adverse reactions to metal debris (ARMD), aseptic lymphocytic vasculitis associated lesion (ALVAL), and pseudotumors. In addition, the dissemination of metal particles and ions throughout the body has been associated with systemic adverse effects, including organ toxicity, cancerogenesis, teratogenicity, and immunotoxicity. As proved by the multitude of studies in this field, metal degradation may increase safety issues associated with THA, especially with MoM hip systems. Data collection regarding local, systemic and long-term effects plays an essential role to better define any safety risks and to generate scientifically based recommendations.