Patch Testing for Evaluation of Hypersensitivity to Implanted Metal Devices: A Perspective From the American Contact Dermatitis Society. Dermatitis. 2016;27:241-247. [PMID: 27649347 DOI: 10.1097/der.0000000000000210]

Contact Dermatitis From Biomedical Devices, Implants, and Metals-Trouble From Within

Allergic contact dermatitis is characterized by its appearance of red, raised and infiltrated, scaling or scabbed skin and intense pruritus, and distinguished from irritant contact dermatitis by its specific immune process and histopathology. Many contact allergens are low-molecular- weight chemicals including metals such as nickel, cobalt, and chromium, preservatives, and adhesives. When such materials are used internally in biomedical devices, they are similarly capable of causing sensitization and an inflammatory response. Sometimes, the reaction remains internal, and presents as swelling, pain, stiffness, decreased range of motion, and internal itching around the implant. Such reactions may, in some cases, also extend to include a localized or, rarely, systemic contact dermatitis indicative of the same process. This review will present an overview of reported skin and local internal reactions to orthopedic implants, which are the largest category of implanted internal metal devices. Immune reactions to smaller categories of medical appliances include cardiac devices and vascular stents, neuromodulation devices, diabetic appliances, Nuss bar surgery for pectus excavatum, and dental and spinal implants. We will review the available diagnostic tools, the consensus on interpretation, and reported strategies for treatment.

Acrylates and Methacrylates Sensitization in Patients with Orthopedic and Dental Prostheses: Asymptomatic Pre-Implant and Symptomatic Post-Implant Testing

Acrylates and methacrylates are widely used in dental and orthopedic prostheses, false nails, adhesives, glues, and paints, and are strong sensitizers. The aim of our study was to assess the prevalence of acrylate sensitization in patients before the application of dental or orthopedic prostheses or after the application in case of potentially related contact dermatitis. Methods: The subjects were tested according to haptens reported in safety data sheets, including methyl methacrylate (MMA) 5%, methyl acrylate (MA) 1%, ethyl methacrylate (EMA) 2%, ethyl acrylate (EA) 1%, butylacrylate 0.1%, 2 hydroxyethyl methacrylate (HEMA) 5%, ethylene glycol dimethacrylate 2% (EGDMA), tetraethylene glycol dimethacrylate 2% (TEGDMA), and dimethyl amino ethyl methacrylate 0.2% (DAEMA). Multivariable logistic regression was used to study the factors associated with (meth)acrylate sensitization. Results: Six hundred sixty-five patients (75.4% of the total sample) without contact dermatitis before the placement of any dental or orthopedic prosthesis and 217 patients (24.6% of the total sample) with contact dermatitis potentially due to already placed prostheses were involved. In total, 37 cases of patch test positivity to at least 1 acrylate (4.2%) were found. In the pre-implant population, previous dermatitis and respiratory allergy were associated with increased sensitization to acrylates in multivariable regression analysis (odds ratio [OR] 2.38, 95% confidence interval [CI] 1.05-5.39; OR 2.96, 95% CI 1.32-6.64, respectively). The prevalence of sensitization was 3.5% for EGDMA, 2.7% for EA, 1.5% for 2-HEMA, 1.4% for both MA and MMA, 1.28% for DAEMA, and 0.8% for EMA. No statistically significant difference was found in the prevalence of sensitization between the pre- and post-implant groups. Discussion: Our study found a similar profile of sensitization in pre-implant and post-implant patients, suggesting the need to better study the specificity and sensitivity of patch tests to (meth)acrylate and to define relevance considering a detailed history of exposure.

Titanium Allergy: A Retrospective Review of 166 Patch Tested Patients

Background: Although most patients do not develop hypersensitivity reactions to metals in implanted devices, when they do occur, significant morbidity can result. Titanium-based systems are often considered as an alternative option in metal-allergic patients; however, there are few studies published on titanium allergy and allergic reactions to titanium in implants may be overlooked in clinical practice. Methods: Our aim was to further characterize a single institution's experience with titanium patch testing and evaluation of titanium allergy. We performed a retrospective medical record review of 166 patients evaluated for titanium contact allergy between January 2018-August 2023. Of the 166 patients in our cohort, 67 were referred for pre-implant patch testing and 64 for post-implant patch testing; 35 were tested for reasons unrelated to an implant. Results: Twenty-six of the 166 patients were PTP to titanium (15.7% positive rate). Titanium PTP rates were higher for post-implant cases (28.1%, 18/64) compared to pre-implant cases (6.0%, 4/67) (χ2 9.97, p = 0.002). Among 18 titanium PTPs identified for the 64 post-implant cases, 8 were likely relevant, 8 possibly relevant, and 2 not likely relevant. Conclusions: Further studies should be performed to evaluate the incidence of allergy to titanium implants and to continue surveillance of changes in sensitization rates.

Metal implant allergy: A retrospective cohort analysis at a university allergy practice

Background: Concern of metal sensitization in pre- and postsurgical evaluation is growing, with the recent guidelines remaining the criterion standard for consideration of patch testing. Information remains scarce on surgical screening in the groups of patients who reported a history of metal sensitivity versus those with no reported history. Objective: The objective of this study was to assess the utility of patch testing in surgical candidates based on reported metal allergy history. The secondary objective was to evaluate the utility and outcomes in postsurgical patch testing. Methods: Nine hundred and thirty-one patient charts of patients with the diagnosis of "contact dermatitis" who underwent an evaluation at a single allergy clinic site between January 2013 and December 2022 were identified and reviewed as part of a retrospective chart review study. Patients were included in subgroups based on the time of patch testing and history of reported metal allergy. Results: In all, 67 patients underwent patch testing, 10 (14.9%) of whom were surgical candidates without a history of metal sensitivity, 31 (46.2%) of whom were surgical candidates with a history of metal sensitivity, and 26 (38.8%) of whom were postsurgical patients. Twenty-nine (43.3%) of patients had positive patch testing results, with only one (10%) in the presurgical group, 17 (54.8%) in the presurgical with a history of metal sensitivity, and 11 (42.3%) in the postsurgical group. Zero patients in our cohort without metal sensitivity who were undergoing the Nuss procedure had positive reactions on patch testing, whereas two of four (50%) with reported metal sensitivity who were undergoing the Nuss procedure had positive relevant metal reactions. Conclusion: Ambiguity in the utility of patch testing for surgical decision making remains, despite common utilization. Recent guidelines along with coordination of care among the surgeon, allergist, and patient remains the criterion standard of care.

No difference in patient reported outcome and inflammatory response after coated and uncoated total knee arthroplasty - a randomized controlled study

BACKGROUND

Allergies against implant materials are still not fully understood. Despite controversies about its relevance, some patients need treatment with hypoallergenic implants. This study compared coated and standard total knee arthroplasty (TKA) regarding inflammatory response and patient-reported outcome measures (PROMs).

METHODS

76 patients without self-reported allergies against implant materials were included in a RCT and received a coated or standard TKA of the same cemented posterior-stabilized knee system. 73 patients completed the 3-year follow-up. Two patients died and there was one revision surgery. Serum levels of cytokines with a possible role in implant allergy were measured in patient`s serum (IL-1beta, IL-5, IL-6, IL-8, IL-10, IFN γ, TNF α) prior to, one and three years after surgery. Furthermore, PROMs including knee function (Oxford Knee Score, Knee Society Score) and health-related quality of life (QoL, EuroQuol questionnaire) were assessed. Additionally, 8 patients with patch-test proven skin allergy against implant materials who received the coated implant were assessed similarly and compared to a matched-pair group receiving the same implant.

RESULTS

There were no differences in function and QoL between the assessed groups at any follow-up. The majority of patients demonstrated no elevation of the measured blood cytokines. Cytokine patterns showed no differences between study groups at any follow-up. The allergy patients demonstrated slower functional improvement and minor differences in cytokine pattern. Yet these results were not significant. There were no differences in the matched-pair analysis.

CONCLUSION

We observed no relevant increase in serum cytokine levels in any group. The inflammatory response measured seems limited, even in allergy patients. Furthermore, there were no differences between coated and standard TKA in non-allergy patients in the 3-year Follow-Up period.

TRIAL REGISTRATION

The study protocol was registered in the US National Institutes of Health's database ( http://www.

CLINICALTRIALS

gov ) registry under NCT03424174 on 03/17/2016.

Systemic allergic contact dermatitis to palladium, platinum, and titanium: mechanisms, clinical manifestations, prevalence, and therapeutic approaches

Contact dermatitis (CD) is an inflammatory skin disease of eczema that is elicited by chemicals or metal ions that have toxic effects without eliciting a T-cell response (contact elicitation) or by small reactive chemicals that modify proteins and induce innate and adaptive immune responses (contact allergens). The clinical condition is characterized by localized skin rash, pruritus, redness, swelling, and lesions, which are mainly detected by patch tests and lymphocyte stimulation. Heavy metals such as palladium (Pd), platinum (Pt), and titanium (Ti) are ubiquitous in our environment. These heavy metals have shown CD effects as allergic agents. Immunological responses result from the interaction of cytokines and T cells. Occupational metal CD accounts for most cases of work-related cutaneous disorders. In this systematic review, the allergic effects of heavy metals, including Pd, Pt, and Ti, and the mechanisms, clinical manifestations, prevalence, and therapeutic approaches are discussed in detail. Furthermore, the therapeutic approaches introduced to treat CD, including corticosteroids, topical calcineurin inhibitors, systemic immunosuppressive agents, phototherapy, and antihistamines, can be effective in the treatment of these diseases in the future. Ultimately, the insights identified could lead to improved therapeutic and diagnostic pathways.

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.

Posterior cerebral artery stenosis related to implanted intracranial electrodes for temporal lobe epilepsy: A case report

INTRODUCTION

Intracranial electroencephalography is a crucial diagnostic technique for epilepsy surgery, though it is associated with a range of complications, including infection, intracranial hemorrhage, increased intracranial pressure, and cerebral infarction. This case study presents an uncommon occurrence of stenosis of the left posterior cerebral artery (PCA) following intracranial electrode implantation.

CASE PRESENTATION

A woman in her thirties with drug-resistant focal impaired awareness seizures underwent implantation of subdural and depth electrodes on the bilateral temporal lobes to lateralize seizure onset. A left anterior-temporal lobectomy was performed based on the evaluation results. Following the resection of the hippocampus, stenosis of the left PCA, with a pinched appearance, was observed. Postoperatively, extensive cerebral edema in the bilateral temporal lobes and a defect in the left PCA were detected on magnetic resonance (MR) imaging. MR imaging performed the day after surgery showed cerebral infarction in the left medial temporal lobe and left lateral thalamus. A video review indicated that surgical manipulation was not the cause of vascular stenosis. MR angiography one week later confirmed the recanalization of the PCA.

DISCUSSION

We surmised that the subdural electrodes inserted along the middle skull base might have induced the PCA stenosis or spasms. The patient did not experience any significant sequelae, with no episodes of seizures for more than five years after surgery.

CONCLUSION

It is essential to note that subdural grid electrodes placed in the medial temporal lobe can cause vascular stenosis, albeit with an extremely rare occurrence.

Cross-Reactivity of Intraoral Allergic Contact Mucositis in the Nickel-Sensitized Ear Model of Metal Allergy

Cross-reactivity of metal allergies can make metal allergy treatment complicated because the background of immune response in cross-reactions remains unknown. In clinical settings, cross-reactivity among several metals has been suspected. However, the precise mechanism of immune response in cross-reactivity is unclear. Two sensitizations with nickel, palladium, and chromium plus lipopolysaccharide solution into the postauricular skin were followed by a single nickel, palladium, and chromium challenge of the oral mucosa to generate the intraoral metal contact allergy mouse model. Results showed that the infiltrating T cells in nickel-sensitized, palladium- or chromium-challenged mice expressed CD8+ cells, cytotoxic granules, and inflammation-related cytokines. Thus, nickel ear sensitization can cause cross-reactive intraoral metal allergy.

Team Approach: Metal Hypersensitivity in Total Joint Arthroplasty

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As total joint arthroplasty volume continues to grow nationwide, more uncommon complications such as metal implant hypersensitivity are reported with greater frequency in the literature.

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Metal hypersensitivity is a challenging diagnosis given the potentially vague symptomology. It should be considered a diagnosis of exclusion, necessitating careful consideration of other potential etiologies of a failing implant before arriving at the final diagnosis of metal hypersensitivity.

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Patients can experience substantial morbidity from implant rejection and in severe, refractory cases may even require revision arthroplasty and conversion to a hypoallergenic implant.

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Given the complex nature of the condition, successful treatment of metal hypersensitivity to orthopaedic implants is best achieved through the use of a multidisciplinary, team-based approach. Immunologists, radiologists, and infectious disease physicians as well as orthopaedic surgeons and mechanical engineers are all vital in appropriate diagnosis and treatment of the condition.

Characterization of the Toxicological Impact of Heavy Metals on Human Health in Conjunction with Modern Analytical Methods

Increased environmental pollution, urbanization, and a wide variety of anthropogenic activities have led to the release of toxic pollutants into the environment, including heavy metals (HMs). It has been found that increasing concentrations of HMs lead to toxicity, mineral imbalances, and serious diseases, which are occurring more and more frequently. Therefore, testing has become imperative to detect these deficiencies in a timely manner. The detection of traces of HMs, especially toxic ones, in human tissues, various biological fluids, or hair is a complex, high-precision analysis that enables early diagnosis, addressing people under constant stress or exposed to a toxic environment; the test also targets people who have died in suspicious circumstances. Tissue mineral analysis (TMA) determines the concentration of toxic minerals/metals at the intracellular level and can therefore determine correlations between measured concentrations and imbalances in the body. Framing the already-published information on the topic, this review aimed to explore the toxicity of HMs to human health, the harmful effects of their accumulation, the advantages vs. the disadvantages of choosing different biological fluids/tissues/organs necessary for the quantitative measurement of HM in the human body, as well as the choice of the optimal method, correlated with the purpose of the analysis.

Preoperative Metal Patch Testing and Titanium Bar Use Criteria in Nuss Procedure: A 56-Patients' Cohort Study

INTRODUCTION

 Nuss procedure is the main reason for metal implants use by pediatric and thoracic surgeons. There is an ongoing debate on how to avoid allergic complications. Herein we describe our 8-year experience with systematic preoperative metal patch testing and our selective titanium bar use in Nuss procedure.

MATERIALS AND METHODS

 This is a single center retrospective observational cohort study of patients who underwent the Nuss procedure from 2013 to 2020. Preoperative metal patch testing was done in all cases. Criteria for titanium bar utilization were: a positive test for a major component of the stainless-steel bar; or a positive metal patch test and a positive history of atopy, food or metal allergy, or previous allergic reaction to an implant or device.

RESULTS

 In total, 56 patients were included. Most were male (91.1%) with a median age of 15.0 (13.0-22.0) years old. 19.6% had a positive preoperative metal patch test and 54.5% of these had no personal history of atopy. Stainless-steel bars were used in 27.3% of those patients and titanium bars were used in 72.7%. One patient had a documented minor allergy reaction. None of the 56 patients required early bar removal.

CONCLUSION

 Our study suggests that routine preoperative allergy testing and a judicious use of titanium bar are safe and avoid metal allergic complications.

Metal Allergy in Tracheostomy Tube Placement Resulting in Complete Subglottic Stenosis: A Case Report

OBJECTIVES

Metal hypersensitivity reaction to surgical implants is a well- known phenomenon that is associated with pain, swelling, inflammation, and decreased efficacy of the implant. We present a unique case of a patient with placement a metal Jackson tracheostomy tube that led to expeditious total subglottic stenosis.

METHODS

The patient was a 33-year old, severely atopic woman with history of asthma exacerbations requiring several intubations for acute respiratory failure with several subsequent tracheal dilations with steroid injections, and eventual tracheostomy placement with a metal Jackson tracheostomy tube that led to expeditious total subglottic stenosis.

RESULTS

Initial intervention included performing an airway evaluation, CO₂ laser, and steroid injection of the area of complete subglottic stenosis. Follow up several months later revealed little improvement in level of tracheal narrowing proximal to the tracheostomy tube. Patient did not have shortness of breath but continued to be aphonic. Cricotracheal versus tracheal resection have been proposed but surgical morbidity was deemed too high due to patient's obesity.

CONCLUSIONS

Metal hypersensitivity reactions are well known phenomena as it relates to surgical implants in other surgical specialties but are seldom reported within the ear, nose and throat literature. Oftentimes, it takes astute observation to diagnose and establish a connection. Prompt recognition and treatment can be acquired from interdisciplinary collaboration with allergy.

Patch testing: Uses, systems, risks/benefits, and its role in managing the patient with contact dermatitis

Patch testing is the gold standard diagnostic tool for cell-mediated type IV hypersensitivity reactions like allergic contact dermatitis. Sensitized individuals have primed antigen-specific T lymphocytes that cause a reaction when antigens are applied to the skin owing to prior sensitization. Patch testing can be used in the adult and pediatric populations, but it is contraindicated in patients with a known history of severe allergic reactions to suspected allergens, generalized active dermatitis, or extensive eczema. Patch test systems can be a comprehensive panel (70-80 allergens), but they can also be targeted and limited to a more common allergen series (35 allergens). The decision for allergen selection should be based on an accurate patient history, physical examination, and availability of allergens. Measurement and interpretation of the test results requires training and experience, as well as consideration of relevance and clinical history. Patch testing is generally considered safe with just a few known complications: excited skin syndrome, active sensitization, and rarely anaphylaxis or other cutaneous complications. Appropriately pretesting patient education can help to mitigate some of these complications. Based on patch testing results, patients should be educated regarding proper allergen avoidance measures to resolve symptoms of allergic contact dermatitis.

Utility of routine patch testing prior to surgical repair of pectus excavatum: A multidisciplinary experience via retrospective review at a single tertiary care center

BACKGROUND

The Nuss procedure is the only implant procedure in which routine, rather than selective, preoperative patch testing is recommended. This practice has recently been called into question.

OBJECTIVE

To evaluate an updated experience of pre-implant patch testing in patients undergoing the Nuss procedure.

METHODS

A retrospective chart review of Nuss procedures from 2012 through 2020.

RESULTS

Forty-five patients were identified for data collection. From 2012 to 2014, none of the 14 patients were patch tested. From 2015 to 2020, 26 of 31 (83.9%) were patch tested. Of those tested, only 2 had a positive patch test. A hypoallergenic titanium bar was inserted in each case. In total, there were zero bar reactions.

CONCLUSION

The risks of patch testing are extremely small and should be weighed against the serious implications of even one bar allergy when deciding on future guidelines.

Immunological Mechanisms of Metal Allergies and the Nickel-Specific TCR-pMHC Interface

Besides having physiological functions and general toxic effects, many metal ions can cause allergic reactions in humans. We here review the immune events involved in the mediation of metal allergies. We focus on nickel (Ni), cobalt (Co) and palladium (Pd), because these allergens are among the most prevalent sensitizers (Ni, Co) and immediate neighbors in the periodic table of the chemical elements. Co-sensitization between Ni and the other two metals is frequent while the knowledge on a possible immunological cross-reactivity using in vivo and in vitro approaches remains limited. At the center of an allergic reaction lies the capability of a metal allergen to form T cell epitopes that are recognized by specific T cell receptors (TCR). Technological advances such as activation-induced marker assays and TCR high-throughput sequencing recently provided new insights into the interaction of Ni2+ with the αβ TCR-peptide-major histocompatibility complex (pMHC) interface. Ni2+ functionally binds to the TCR gene segment TRAV9-2 or a histidine in the complementarity determining region 3 (CDR3), the main antigen binding region. Thus, we overview known, newly identified and hypothesized mechanisms of metal-specific T cell activation and discuss current knowledge on cross-reactivity.

Metal allergy in primary and revision total knee arthroplasty : a scoping review and evidence-based practical approach

AIMS

Metal allergy in knee arthroplasty patients is a controversial topic. We aimed to conduct a scoping review to clarify the management of metal allergy in primary and revision total knee arthroplasty (TKA).

METHODS

Studies were identified by searching electronic databases: Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and Embase, from their inception to November 2020, for studies evaluating TKA patients with metal hypersensitivity/allergy. All studies reporting on diagnosing or managing metal hypersensitivity in TKA were included. Data were extracted and summarized based on study design, study population, interventions and outcomes. A practical guide is then formulated based on the available evidence.

RESULTS

We included 38 heterogeneous studies (two randomized controlled trials, six comparative studies, 19 case series, and 11 case reports). The evidence indicates that metal hypersensitivity is a rare complication with some histopathological features leading to pain and dissatisfaction with no reliable screening tests preoperatively. Hypoallergenic implants are viable alternatives for patients with self-reported/confirmed metal hypersensitivity if declared preoperatively; however, concerns remain over their long-term outcomes with ceramic implants outperforming titanium nitride-coated implants and informed consent is paramount. For patients presenting with painful TKA, metal hypersensitivity is a diagnosis of exclusion where patch skin testing, lymphocyte transformation test, and synovial biopsies are useful adjuncts before revision surgery is undertaken to hypoallergenic implants with shared decision-making and informed consent.

CONCLUSION

Using the limited available evidence in the literature, we provide a practical approach to metal hypersensitivity in TKA patients. Future national/registry-based studies are needed to identify the scale of metal hypersensitivity, agreed diagnostic criteria, and management strategies. Cite this article: Bone Jt Open 2021;2(10):785-795.

Influence of Psychological Distress in Patients with Hypoallergenic Total Knee Arthroplasty. Treatment Algorithm for Patients with Metal Allergy and Knee Osteoarthritis

The outcome in total knee arthroplasty (TKA) depends on multiples factors, among them is the psychological condition. In addition, up 15 to 30% of the patients that undergo TKA show little or no improvement after surgery, which implies the diagnosis of a painful TKA is a challenge for the orthopedic surgeon, who must rule out a possible metal allergy (MA). It is considered an exclusion diagnosis. Due to the complex relationship between psychological condition and MA, and according to the worse results in patients treated with a hypoallergenic TKA, we asked: (1). What degree of psychological distress (PD) is present in patients who have a hypoallergenic TKA, and how does it influence the results of quality of life (QoL) and functional capacity. (2). Can we develop a new algorithm for patients with a possible MA that improves the outcomes? A pragmatic clinical study was carried out that included patients who underwent hypoallergenic TKA during three consecutive years. Quality of life and functional capacity were measured with (Western Ontario McMaster Universities Osteoarthritis Index) WOMAC index, the Short Form 12 questionnaire (SF-12) questionnaire, and the The EQ-5D-5L questionnaire essentially consists of two pages: the EQ-5D descriptive system and the EQ visual analogue scale (EQ VAS) (Euro-QoL-5D L-VAS (EQ5D)), in all patients. To assess PD, a Psychological Distress Score was developed. SPSS software was performed to statistical analysis, and Student´s test for independent variables with a p < 0.005 as statistically significant. A total of 72 anallergic TKAs in 64 patients were treated during this period; 31.3% of these patients showed features of PD before the surgery. According with the severity of the PD, 60% were classified as severe, 10% as moderate and 30% as mild. Patients with PD had statistically significant worse results on the final WOMAC, SF-12, and EQ5D questionnaires. The final scores of the physical subscale of the SF-12 and EQ5D showed better results in patients diagnosed by psychiatrist. Up to one third of the patients with hypoallergenic TKAs have PD, and their results are clearly inferior to those patients with MA without PD. When PD was diagnosed according with Psychological Distress Score, patients should be carefully assessed in order to determine if a specialist referral is recommended. According with our results, PD should be assessed either by the PCP or by us. If the PD is confirmed, a psychiatry referral is then requested for better preoperative management and treatment. We believe that this approach would lead to better TKA outcomes.

Contact dermatitis

Contact dermatitis (CD) is among the most common inflammatory dermatological conditions and includes allergic CD, photoallergic CD, irritant CD, photoirritant CD (also called phototoxic CD) and protein CD. Occupational CD can be of any type and is the most prevalent occupational skin disease. Each CD type is characterized by different immunological mechanisms and/or requisite exposures. Clinical manifestations of CD vary widely and multiple subtypes may occur simultaneously. The diagnosis relies on clinical presentation, thorough exposure assessment and evaluation with techniques such as patch testing and skin-prick testing. Management is based on patient education, avoidance strategies of specific substances, and topical treatments; in severe or recalcitrant cases, which can negatively affect the quality of life of patients, systemic medications may be needed.

Patch Test Results and Outcome in Patients with Complications from Total Knee Arthroplasty: A Consecutive Case Series

The role of hypersensitivity in implant-related complications remains controversial. The objectives of our study were to (1) establish the prevalence of hypersensitivity to components of knee prostheses in patients referred to our contact dermatitis clinic, (2) determine if patients with post-surgery dermatitis have become sensitized, and (3) describe the outcome of patients with and without hypersensitivity. We reviewed the charts of patients referred from 2007 to 2018 and extracted demographic information, date, type, and site of implant, clinical presentation, and results of patch testing (PT) or lymphocyte transformation tests (LTT). We called most patients to gather data such as clinical outcome, nature, and timing of additional surgery. Statistical analysis included computation of conventional descriptive statistics. Because of the type of study design, only some categorical variables were tested for possible associations by analytical tools (cross-tabulation). Thirty-nine patients, 23 men (59.0%), and 16 women (41.0%), were included. Their mean age in years was 63.3 (95% confidence interval [CI]: 60.9-65.7) ranging from 39.0 to 79.0, (standard deviation) = 9.69, without statistically significant differences between males and females. Five patients had positive PT possibly relevant to their implant. Four patients had revision surgery and two improved. Of nine patients with dermatitis, one with relevant PT did not improve after revision, and the dermatitis was unrelated to TKA in eight. Of the 26 patients without dermatitis or relevant PT results, 9 had revisions because of incapacitating symptoms, and 5 improved. Hypersensitivity to implant components is a potential factor in the etiology of TKA complications. Patients with confirmed hypersensitivity may benefit from revision. Our study, however, did not detect statistically significant differences in outcome of revision surgery between patients with positive versus negative PT or LTT. In spite of this, we consider that patients with a history suggestive of metal, acrylate or aminoglycoside allergy should be tested preoperatively to avoid hypersensitivity-related postoperative complications. In the absence of hypersensitivity, some patients with incapacitating symptoms may also improve following revision.

Allergy Considerations in Implanted Neuromodulation Devices

OBJECTIVES

Allergic reactions are rare and poorly understood complications of neuromodulation device implantation. There are currently no guidelines for management of allergic reactions to these devices and their components. Here we review the published cases of allergic reactions to implanted neuromodulatory devices and leverage the experiences of other specialties that deal with similar complications to formulate recommendations for prevention and management.

MATERIALS AND METHODS

A review and assessment of the literature.

RESULTS

Allergic reactions to a number of implantable devices have been observed and published. In dentistry and orthopedics, metals such as nickel are the most frequent cause of allergic reactions. In interventional cardiology, where devices closely resemble neuromodulatory devices, titanium, silicone, and polyurethanes are the most common causes of allergic reactions. In neurosurgery, allergic reactions to implantable neuromodulatory devices are rare, and we summarize 13 cases published to date. Such allergic reactions generally present as local dermatitis, erythema, and pruritus, which can be difficult to distinguish from surgical site infection. In one published case, symptoms resolved with corticosteroid treatment, but all other cases required explantation. The successful reimplantation with a modified device was reported in some cases.

CONCLUSIONS

Patients should be screened for a personal history of contact allergy before implantation procedures. A multidisciplinary approach to suspected cases of postoperative allergic reactions involving collaboration between neurosurgeons and other implanting physicians, dermatologists or allergists, and device manufacturers is recommended. In cases where an allergic reaction is suspected, an infectious etiology should be ruled out first. Clinical suspicion can then be supported with the use of patch testing, interpreted by an experienced dermatologist or allergist. If patch testing supports an allergic etiology, the implanting physician and the device manufacturer can work together to modify the device for safe reimplantation.

Metal allergy after the Nuss procedure for pectus excavatum: a review

Minimally invasive repair of pectus excavatum (MIRPE) technique (the Nuss procedure) is a minimally-invasive method that is commonly used in the treatment of pectus excavatum. An allergic reaction to the metal alloy bar that is implanted in the thorax during the procedure is a reported complication. We briefly review current literature concerning epidemiology, mechanisms and research results of allergic reactions after Nuss bar implantation. This allergic reaction occurs in approximately 2.7% of patients and is caused by metals used in the medical implant. The most common symptoms include fever and skin lesions such as allergic dermatitis. Elevated levels of C-reactive protein is a frequent finding in laboratory tests. In order to minimize the risk of such complications, taking a detailed allergy-based medical history and conducting allergy tests, i.e. patch test are required. Allergic reactions can be managed with conservative treatment such as general or topical glucocorticosteroid therapy and antihistamine agents. Severe allergic reactions can be addressed by implant revision, replacement of the steel bar with a titanium substitute or removal of the stabilization at all. Although the risk of an allergic reaction to titanium is smaller it still exists, the titanium substitute is not routinely used due to its higher cost and lesser plasticity which has a negative impact on matching a stabilizing bar during the surgery. Surgeons treating pectus excavatum should remember about the possible allergic reactions after implantation of the metal bar and be familiar with methods of diagnosis and treatment of those complications.

Self-reported metal hypersensitivity in patients undergoing unicondylar knee arthroplasty

OBJECTIVES

There is ongoing discussion about arthroplasty surgery of patients with metal hypersensitivity. The aim of this study was to compare the functional outcomes and eosinophil counts of unicondylar knee arthroplasty (UKA) patients with and without a history of metal hypersensitivity.

METHODS

A retrospective review was made of the medical records of 148 extremities of 140 consecutive patients who underwent primary UKA between January 2016 and December 2017. The patients who met the inclusion criteria were screened for history of metal hypersensitivity using a questionnaire. The functional outcomes of patients and eosinophil levels were evaluated immediately before and at 6 weeks after surgery.

RESULTS

The mean follow-up period was 37 months (range, 18-48 months). Of the total 128 patients, 13 (10.2%) reported a history of metal hypersensitivity before the operation. There was no statistically significant difference between patients with or without a history of metal hypersensitivity in respect of the functional outcomes or eosinophil counts (p > 0.05).

CONCLUSIONS

The results of this study showed that the functional outcomes of patients who underwent UKA using a standard alloy did not change between the groups who reported having or not having a history of metal hypersensitivity. Although the study also showed that the eosinophil counts decreased after surgery compared to the preoperative counts, there was no statistical relationship between the eosinophil count and functional outcomes or metal hypersensitivity history.

Prevalence of metal hypersensitivity in patients with shoulder pathologies

BACKGROUND

To date, medical history and dedicated questionnaires are the fastest and easiest way to assess risks of joint metal hypersensitivity. No published studies determined the overall prevalence of hypersensitivity to metals in patients with shoulder pathologies. The purpose of this study was therefore to estimate the prevalence of metal hypersensitivity reported by patients with shoulder pathologies, and to identify patients at risk of joint metal hypersensitivity based on a dedicated questionnaire.

METHODS

The authors prospectively asked all adult patients consulting for shoulder pathologies between September 2018 and February 2019 at 10 centers to fill in a form. The main outcome was "reported hypersensitivity to metals," comprising belt buckles, coins, earrings, fancy jewelry, keys, leather, metallic buttons, piercings, spectacles, watch bracelets, or zips.

RESULTS

A total of 3217 patients agreed to fill in the survey, aged 55 ± 16 (range, 18-101) with equal proportions of men (51%) and women (49%), and a majority of patients consulting for cuff pathology (55%). A total of 891 (28%) patients had professions considered at risk for metal hypersensitivity. The most frequently reported metal hypersensitivities were fancy jewelry (15%), earrings (13%), and watch bracelets (9%). A total of 629 (20%) patients, of which the vast majority were women, reported hypersensitivity to 1 or more metals.

CONCLUSIONS

This survey of 3217 patients identified 20% who reported metal hypersensitivities, though only 2.2% had done patch tests. Matching profiles of those with positive patch tests to those with no patch tests revealed that 9.4% of the total cohort had similar sex and self-reported metal hypersensitivities. Factors associated with a positive patch test were female sex, self-reported cutaneous allergy, and self-reported metal hypersensitivity. The clinical applicability of these estimates remains uncertain as there is insufficient evidence that allergy to metal implants can be predicted by questionnaires or patch tests.

Patch Testing With an Extended Metal Allergen Series at the Massachusetts General Hospital (2006-2017)

BACKGROUND

Reports of patch test data with an extended metal series that includes rare metals are limited.

OBJECTIVE

The aims of the study were to analyze and report patch testing results from an extended metal series, examine associations with sex and age, and highlight concomitant metal reactions.

METHODS

This study is a retrospective review of 150 patients referred for suspected metal allergy from January 1, 2007, to December 31, 2016.

RESULTS

The most common indications for evaluation referral were those having symptoms after implantation of a metal device (55.3%) and those with a history and concern of metal allergy before implantation of a metal device (22.0%). One or more positive patch test reactions were observed in 87 patients (58.0%). Metals with the highest frequencies were nickel sulfate 2.5% (26.2%), gold sodium thiosulfate 0.5% (23.0%), gold sodium thiosulfate 2.0% (20.7%), palladium chloride 2.0% (19.6%), cobalt chloride 1.0% (12.0%), and manganese chloride 2.0% (10.1%). Of the 45 metals tested, 15 caused no patch test reactions. Female patients were more likely to be sensitized to nickel, gold, and palladium (P < 0.05). Younger patients (≤40 years) had higher reaction rates to nickel, mercury, palladium, and cobalt. Concomitant reactions of the top metals (nickel, palladium, gold, and cobalt) were statistically associated bidirectionally (P < 0.05), except for cobalt and gold.

CONCLUSIONS

Allergy to metals, including those not included in standard series, may be more prevalent than previously suspected. Results may help guide future testing for suspected metal allergy, although future studies are warranted.

Surgical explantation of atrial septal closure devices for refractory nickel allergy symptoms

OBJECTIVES

Systemic allergic reactions to nickel alloys in percutaneous atrial septal defect occlusion devices have a poorly defined natural history. We describe our experience of surgical removal of the offending device in a series of patients with nickel allergy and refractory symptoms.

METHODS

Patients with atrial septal defect device explants for nickel allergy were reviewed. Administered questionnaires focused on symptoms, quality of life, and satisfaction along with the 36-Item Short Form Health Survey to measure physical and mental health postsurgery.

RESULTS

Atrial septal defect devices were removed for nickel allergy in 58 patients during the past 10 years. The median age was 42 years (range, 24-71 years) and 95% were women. Explantation occurred at a median of 8 years (range, 6 months-18 years) after insertion. Symptoms included fatigue (82%), chest pain (78%), headache (73%), and palpitation (58%). Surveys were available for 45 patients: 58% rated their quality of life as poor and 69% were not at all satisfied with their device. Postexplant, all patients reported improvement in their symptoms, with 18 patients (42%) noting complete resolution. In 12 patients prospectively studied, the preoperative scores in physical and mental health domains were lower than the validation group, indicating significant disability. Similarly, there was marked improvement in each domain postremoval.

CONCLUSIONS

Patients with nickel allergy and severe refractory symptoms after atrial septal defect device implantation experience profound resolution of symptoms and improved quality of life after removal. Nickel allergy should be considered before device insertion, and a low threshold should exist for surgical removal for refractory symptoms.

Utility of Patch Testing and Lymphocyte Transformation Testing in the Evaluation of Metal Allergy in Patients with Orthopedic Implants

Total joint arthroplasties are increasingly common orthopedic procedures performed throughout the United States. Implant failure after these procedures occurs due to a number of causes such as infection or mechanical problems, with metal hypersensitivity being an area of growing interest. The nature and mechanism of a causative relationship between metal hypersensitivity and implant failure have been unclear as it is not known whether implant failure occurs due to a previous metal allergy or metal allergy results from secondary sensitization via metal exposure in existing failing implants. Overall, there appears to be growing support and evidence for metal-hypersensitive patients having worse outcomes with regard to total hip and knee arthroplasties. However, there are conflicting recommendations (outside of Nuss procedures) for pre-implant testing for metal hypersensitivity as testing has not consistently been shown to change patient outcomes.

Revision temporomandibular joint arthroplasty for the treatment of acquired metal allergy and review of the literature

The purpose of this study was to examine the outcomes of patients who received revision temporomandibular joint (TMJ) arthroplasty for the treatment of acquired metal allergy. It was hypothesized that subjects would have significant improvements in pain, swelling, and function. Patients who underwent TMJ revision due to nickel allergy were identified retrospectively. Outcomes documented included the presence or absence of facial erythema and facial swelling. Maximum incisal opening was also measured. Additional outcomes collected included age at initial surgery, initial TMJ device type, presenting symptoms, and TMJ device used for surgical revision. Four patients were identified with a nickel allergy to their TMJ prosthesis (containing nickel). All subjects experienced pain and swelling as their primary symptoms prior to the revision, with two subjects showing dermatological symptoms of overlying erythema. The four female subjects underwent exchange of their previously implanted prosthesis with a titanium alloy prosthesis. Postoperatively, all subjects showed improvements in pain score, resolution of swelling and erythema, and improvements in maximum incisal opening. This small case series suggests that revision TMJ arthroplasty with a titanium alloy prosthesis is a potential treatment for acquired metal allergy from traditional TMJ prosthesis implantation.

Exploring the Incidence, Implications, and Relevance of Metal Allergy to Orthopaedic Surgeons

Introduction:

Allergic reactions to metal implants are increasingly recognized, but its relevance to the orthopaedic surgeon remains unclear. We evaluate the prevalence of metal allergies in a subset of the population and review the significance through a survey of the current literature.

Methods:

Preoperative and postoperative patients referred for metal allergy testing were divided into two groups; those with a history of dermatitis and those without. Patients with a history of dermatitis were offered skin patch testing that included the North American Contact Dermatitis core allergen panels in addition to our metal screening series. Patients without dermatitis were tested to the more limited patch testing metal screening series. Some patients with dermatitis opted for the more limited screening, whereas some patients without dermatitis underwent more extensive testing at their request or at the request of the referring clinician. Patch tests were evaluated at 2 and 4 days after placement.

Results:

Hundred patients were referred for metal allergy testing, 46 of whom were for reasons related to planned orthopaedic surgery. Of those tested, 60 patients had a history of dermatitis and 40 did not. Some patients were nonreactive to all tested allergens, whereas others demonstrated one or more positive skin patch test reactions. The number of positive reactions to each metal in patients with a history of dermatitis was the following: nickel 19, amalgam 10, palladium 10, copper 8, cobalt 5, mercury 5, tin 2, gold 1, titanium 1, and vanadium 1. The number of positive reactions to metals in patients without a history of dermatitis was the following: nickel 4, amalgam 5, palladium 4, mercury 4, cobalt 4, tin 2, copper 2, gold 1, vanadium 1, and molybdenum 1.

Discussion:

Metal allergy was common in the individuals referred for testing, with reactions to nickel and amalgam being the most commonly encountered. Some individuals experience more notable allergic reactions to implanted devices than others. Localized and generalized skin reactions have been reported, along with implant failure and loosening. Surgeons should be aware of the incidence of metal allergies and the potential consequences.

Allergy in total knee replacement surgery: Is it a real problem?

Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.

Pulsed Laser Deposited Biocompatible Lithium-Doped Hydroxyapatite Coatings with Antimicrobial Activity

Simple and lithium-doped biological-origin hydroxyapatite layers were synthesized by Pulsed Laser Deposition technique on medical grade Ti substrates. Cytotoxic effects of lithium addition and the biocompatibility of obtained coatings were assessed using three cell lines of human origin (new initiated dermal fibroblasts, immortalized keratinocytes HaCaT, and MG-63 osteosarcoma). Antimicrobial properties of obtained coatings were assessed on two strains (i.e., Staphylococcus aureus and Candida albicans), belonging to species representative for the etiology of medical devices biofilm-associated infections. Our findings suggest that synthesized lithium-doped coatings exhibited low cytotoxicity on human osteosarcoma and skin cells and therefore, an excellent biocompatibility, correlated with a long-lasting anti-staphylococcal and -fungal biofilm activity. Along with low fabrication costs generated by sustainable resources, these biological-derived materials demonstrate their promising potential for future prospective solutions—viable alternatives to commercially available biomimetic HA implants—for the fabrication of a new generation of implant coatings.

Letter to the Editor: Metal hypersensitivity reactions in the context of Essure™

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Allergic systemic contact dermatitis has been reported with the use of Essure™.

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Hypersensitivity may be considered upon exclusion of common pelvic disease etiologies.

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Asymptomatic, functioning implanted devices do not warrant patch testing or removal.

Patch Testing for the Evaluation of Metal Hypersensitivity in the Nuss Procedure

The Nuss procedure has become the predominant reason for the use of metal implants by pediatric general and thoracic surgeons. Current guidelines recommend preimplant testing for all patients undergoing the Nuss procedure, which differs from the guidelines for all other orthopedic procedures. This review was done to further evaluate this discrepancy.

Metal hypersensitivity in the context of connective tissue disease - An opportunity for practice prevention

Metal hypersensitivity reactions (MHR) are not associated with metal containing orthodontic implants unless there is a positive history of dermatitis from a high nickel-release item (piercing post, earring, watch). We wish to present this letter to highlight evidence surrounding orthodontic-related nickel hypersensitivity and to bring to the readers attention current American Contact Dermatitis Society (ACDS) guidelines that endorse the importance of addressing metal hypersensitivity reactions in the setting of implantable dental devices.

Assessing the validity of self-reported history of rash caused by metal or jewellery

BACKGROUND

The use of metal-containing bio-devices is becoming increasingly common. Self-reported history of dermatitis with metal exposure is not established as being predictive for metal allergy.

OBJECTIVES

To assess the validity of two screening questions addressing metal allergy.

METHODS

At Massachusetts General Hospital Contact Dermatitis Clinic, 2132 consecutive patients were asked either 'Do you get rashes when jewellery touches your skin' (Q1; N = 1816) or 'Do you get rashes when metal touches your skin?' (Q2; N = 316) before being patch tested.

RESULTS

Testing showed that 20% of subjects had positive reactions to nickel, 7.4% had positive reactions to cobalt, and 5.8% had positive reactions to chromium. Q1 was 40% sensitive (95%CI: 35-45%). The positive predictive value (PPV) was 51%, and the negative predictive value (NPV) was 82%. Q2 was 77% sensitive (95%CI: 68-84%). The PPV was 71%, and the NPV was 84%. Q2 was 37% more sensitive than Q1 (p < 0.0001), with a higher relative risk (RR) (4.75, p < 0.001) than Q1 (RR = 3.01, p < 0.001).

CONCLUSIONS

Patient-reported metal allergy, although not perfect, is a reasonable method for metal allergy screening to help identify those needing further objective evaluation by patch testing.

Hypersensitivity to Orthopedic Implants: A Review of the Literature

Awareness of rare etiologies for implant failure is becoming increasingly important. In addition to the overall increase in joint arthroplasties, revision surgeries are projected to increase dramatically in the coming years, with volume increasing up to seven-fold between 2005 and 2030. The literature regarding the relationship between metal allergy and implant failure is controversial. It has proven difficult to determine whether sensitization is a cause or a consequence of implant failure. Testing patients with functional implants is not a clinically useful approach, as the rate of hypersensitivity is higher in implant recipients than in the general population, regardless of the status of the implant. As a result of the ineffectiveness of preoperative patch testing for predicting adverse outcomes, as well as the high cost of implementing such patch testing as standard procedure, most orthopedists and dermatologists agree that an alternative prosthesis should only be considered for patients with a history of allergy to a metal in the standard implant. In patients with a failed implant requiring revision surgery, hypersensitivity to an implant component should be considered in the differential diagnosis. Because a metal allergy to implant components is currently not commonly considered in the differential for joint failure in the orthopedic literature, there should be improved communication and collaboration between orthopedists and dermatologists when evaluating joint replacement patients with a presentation suggestive of allergy.

Surgery-Related Contact Dermatitis: A Review of Potential Irritants and Allergens

Surgical procedures utilize an increasing number of medical products including antiseptics, anesthetics, gloves, suture materials, tissue adhesives, topical antibiotics, and bandages. Many of these products have irritant potential. Allergic contact dermatitis has also been reported. This review covers preoperative, operative, and postoperative exposures that may result in contact dermatitis. Testing with standard patch panels such as T.R.U.E. Test and the North American Contact Dermatitis Group 65 allergen series does not evaluate for all relevant contactants. A thorough understanding of potential exposures is vital to effectively evaluate a patient with surgery-related contact dermatitis. A systematic approach is needed to ensure that standard patch panels and supplementary patches adequately address each encountered contactant.