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Filliquist B, McKay R, Marcellin-Little DJ, Irvin JJ, Garcia TC, Vernau W, Chou PY, Kapatkin AS, Vapniarsky N. Metal reactivity is present in dogs with tibial plateau leveling osteotomy and total hip replacement implants. Am J Vet Res 2023; 84:ajvr.22.08.0141. [PMID: 36652332 DOI: 10.2460/ajvr.22.08.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/25/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Determine whether dogs with well-functioning orthopedic metal implants can develop metal reactivity. SAMPLE Client-owned dogs that had tibial plateau leveling osteotomy (TPLO) or total hip replacement (THR) implants for 12 months or more and control dogs with no implants. PROCEDURES Lymphocyte transformation testing was performed by exposing peripheral blood lymphocytes to nickel (Ni), chromium (Cr), cobalt (Co), or a combination of these metals. Lymphocyte proliferation was assessed with flow cytometry. Lymphocyte stimulation indexes (SIs) were calculated. A SI > 2 was considered reactive. Median SIs of dogs in response to metal exposure were compared statistically. RESULTS Samples from 10 dogs with TPLO, 12 dogs with THR, and 7 control dogs were analyzed. Six dogs out of 22 with metal implants had a reactive SI to 1 or more metals, while 2 of 7 control dogs had a SI > 2 when exposed to nickel only. When all metals were considered, no differences in metal reactivity were found between TPLO, THR, and control groups. CLINICAL RELEVANCE Metal reactivity is present in dogs and can be identified using lymphocyte transformation testing. Reactivity to Ni is present in dogs with and without metal implants. Reactivity to Co and Cr occurs in some dogs with metal implants.
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Affiliation(s)
- Barbro Filliquist
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA.,JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Rachel McKay
- Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Denis J Marcellin-Little
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA.,JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Justine J Irvin
- JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Tanya C Garcia
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA.,JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - William Vernau
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Po-Yen Chou
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA.,JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Amy S Kapatkin
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA.,JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Natalia Vapniarsky
- JD Wheat Veterinary Orthopedic Laboratory, School of Veterinary Medicine, University of California-Davis, Davis, CA.,Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California-Davis, Davis, CA
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Ort MJ, Geissler S, Rakow A, Schoon J. The Allergic Bone Marrow? The Immuno-Capacity of the Human Bone Marrow in Context of Metal-Associated Hypersensitivity Reactions. Front Immunol 2019; 10:2232. [PMID: 31620137 PMCID: PMC6759684 DOI: 10.3389/fimmu.2019.02232] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022] Open
Abstract
Arthroplasty ranks among the greatest achievements of surgical medicine, with total hip replacement termed “the operation of the century.” Despite its wide success, arthroplasty bears risks, such as local reactions to implant derived wear and corrosion products. Prevalence of allergies across Western society increases and along the number of reported hypersensitivity reactions to orthopedic implant materials. In this context the main focus is on delayed hypersensitivity (DTH). This mechanism is mainly attributed to T cells and an overreaction of the adaptive immune system. Arthroplasty implant materials are in direct contact with bone marrow (BM), which is discussed as a secondary lymphoid organ. However, the mechanisms of sensitization toward implant wear remain elusive. Nickel and cobalt ions can form haptens with native peptides to activate immune cell receptors and are therefore common T helper allergens in cutaneous DTH. The rising prevalence of metal-related allergy in the general population and evidence for the immune-modulating function of BM allow for the assumption hypersensitivity reactions could occur in peri-implant BM. There is evidence that pro-inflammatory factors released during DTH reactions enhance osteoclast activity and inhibit osteoblast function, an imbalance characteristic for osteolysis. Even though some mechanisms are understood, hypersensitivity has remained a diagnosis of exclusion. This review aims to summarize current views on the pathomechanism of DTH in arthroplasty with emphasis on BM and discusses recent advances and future directions for basic research and clinical diagnostics.
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Affiliation(s)
- Melanie J Ort
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg School for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sven Geissler
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg School for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anastasia Rakow
- Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Janosch Schoon
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg School for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
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Teo WZW, Schalock PC. Metal Hypersensitivity Reactions to Orthopedic Implants. Dermatol Ther (Heidelb) 2017; 7:53-64. [PMID: 27995484 PMCID: PMC5336431 DOI: 10.1007/s13555-016-0162-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Indexed: 01/08/2023] Open
Abstract
Total hip and knee replacement surgery using metal alloy devices is common. Type IV allergic reactions to these implants occur, though infrequently. While uncommon, peri-implant metal allergic reactions may cause significant morbidity for the affected individual-including aseptic loosening, pseudotumor formation and frank device failure. It is challenging to predict who will have these reactions, even in those with established pre-implant metal allergy. At this time, the scientific literature clearly supports few conclusions. Despite this, we believe several conclusions can be made: routine pre-implant testing in asymptomatic individuals is not indicated; listen to patient's concerns about metal allergy if the concern arises; patch testing is probably the best pre- and post-implant screening test; post-implantation testing is controversial and even positive LTT or patch test does not definitively diagnose morbidity from a metal allergy; and complete recovery following revision placement of an immunologically inert device is diagnostic. More research is needed to scientifically approach this issue.
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Affiliation(s)
- Wendy Z W Teo
- Department of Surgery (Dermatology), Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Peter C Schalock
- Department of Surgery (Dermatology), Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
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5
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Thomas P, Summer B. Diagnosis and management of patients with allergy to metal implants. Expert Rev Clin Immunol 2015; 11:501-9. [DOI: 10.1586/1744666x.2015.1016501] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lübbeke A, Rothman KJ, Garavaglia G, Barea C, Christofilopoulos P, Stern R, Hoffmeyer P. Strong association between smoking and the risk of revision in a cohort study of patients with metal-on-metal total hip arthroplasty. J Orthop Res 2014; 32:762-8. [PMID: 24615914 DOI: 10.1002/jor.22603] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 02/03/2014] [Indexed: 02/04/2023]
Abstract
Thus far the ability to predict who will develop early failure following the insertion of a metal-on-metal (MoM) bearing has been very limited. Our objective was to assess the effect of smoking on failure rates in patients with MoM bearing, compared with patients with ceramic-on-polyethylene (CoP) bearing. From a prospective hospital-based registry we included all primary THAs operated upon between 1/2001 and 12/2011 with MoM or CoP bearings of the same cup design and head size (28 mm). We compared revision rates through 10/2013 classified by smoking status and type of bearing. We included 1,964 patients (median age 71, 57% women), 663 with MoM and 1,301 with CoP bearing. Mean follow-up was 6.9 years (range 1.8-12.8). Revisions were required for 56 THAs. In patients with MoM bearing the adjusted incidence rate of revision among ever-smokers was four times greater than among never-smokers (95% CI 1.4-10.9). Among those with CoP bearing, the rate ratio was only 1.3 (95% CI 0.6-2.5). We found a strong association between smoking and increased failure of MoM THAs. In contrast, the association was weak for patients with CoP bearing. Smoking might be a trigger or an effect amplifier for adverse reactions to metal debris from MoM bearings.
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Affiliation(s)
- Anne Lübbeke
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals and Geneva University, Rue Gabrielle-Perret-Gentil, Geneva, CH-1211, Switzerland
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Svedman C, Möller H, Gruvberger B, Gustavsson CG, Dahlin J, Persson L, Bruze M. Implants and contact allergy: are sensitizing metals released as haptens from coronary stents? Contact Dermatitis 2014; 71:92-7. [DOI: 10.1111/cod.12242] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 03/05/2014] [Accepted: 03/05/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Cecilia Svedman
- Department of Occupational Environmental Dermatology; Skåne University Hospital, Lund University; 205 02 Malmö Sweden
| | - Halvor Möller
- Department of Occupational Environmental Dermatology; Skåne University Hospital, Lund University; 205 02 Malmö Sweden
| | - Birgitta Gruvberger
- Department of Occupational Environmental Dermatology; Skåne University Hospital, Lund University; 205 02 Malmö Sweden
| | - Carl-Gunnar Gustavsson
- Department of Cardiology; Skåne University Hospital, Lund University; 205 02 Malmö Sweden
| | - Jakob Dahlin
- Department of Occupational Environmental Dermatology; Skåne University Hospital, Lund University; 205 02 Malmö Sweden
| | - Lena Persson
- Department of Occupational Environmental Dermatology; Skåne University Hospital, Lund University; 205 02 Malmö Sweden
| | - Magnus Bruze
- Department of Occupational Environmental Dermatology; Skåne University Hospital, Lund University; 205 02 Malmö Sweden
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Buyukozturk S, Gelincik A, Demirtürk M, Erdoğdu D, Pur L, Çolakoğlu B, Deniz G, Erdem Kuruca S. Nickel dental alloys can induce laryngeal edema attacks: A case report. J Dermatol 2013; 40:740-2. [DOI: 10.1111/1346-8138.12210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 05/08/2013] [Indexed: 12/01/2022]
Affiliation(s)
- Suna Buyukozturk
- Division of Allergy; Department of Internal Medicine; Istanbul Faculty of Medicine; Istanbul; Turkey
| | - Asli Gelincik
- Division of Allergy; Department of Internal Medicine; Istanbul Faculty of Medicine; Istanbul; Turkey
| | - Mustafa Demirtürk
- Division of Allergy; Department of Internal Medicine; Istanbul Faculty of Medicine; Istanbul; Turkey
| | - Derya Erdoğdu
- Division of Allergy; Department of Internal Medicine; Istanbul Faculty of Medicine; Istanbul; Turkey
| | - Leyla Pur
- Immunology Department; Institute of Experimental Medicine; Istanbul; Turkey
| | - Bahattin Çolakoğlu
- Division of Allergy; Department of Internal Medicine; Istanbul Faculty of Medicine; Istanbul; Turkey
| | - Gunnur Deniz
- Immunology Department; Institute of Experimental Medicine; Istanbul; Turkey
| | - Serap Erdem Kuruca
- Department of Physiology; Istanbul Faculty of Medicine; Istanbul University; Istanbul; Turkey
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Commentary on Crawford, et al, The Role of Patch Testing in the Evaluation of Orthopedic Implant-Related Adverse Effects. Dermatitis 2013; 24:108-11. [DOI: 10.1097/der.0b013e3182979722] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Granchi D, Cenni E, Giunti A, Baldini N. Metal hypersensitivity testing in patients undergoing joint replacement: a systematic review. ACTA ACUST UNITED AC 2012; 94:1126-34. [PMID: 22844057 DOI: 10.1302/0301-620x.94b8.28135] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
We report a systematic review and meta-analysis of the peer-reviewed literature focusing on metal sensitivity testing in patients undergoing total joint replacement (TJR). Our purpose was to assess the risk of developing metal hypersensitivity post-operatively and its relationship with outcome and to investigate the advantages of performing hypersensitivity testing. We undertook a comprehensive search of the citations quoted in PubMed and EMBASE: 22 articles (comprising 3634 patients) met the inclusion criteria. The frequency of positive tests increased after TJR, especially in patients with implant failure or a metal-on-metal coupling. The probability of developing a metal allergy was higher post-operatively (odds ratio (OR) 1.52 (95% confidence interval (CI) 1.06 to 2.31)), and the risk was further increased when failed implants were compared with stable TJRs (OR 2.76 (95% CI 1.14 to 6.70)). Hypersensitivity testing was not able to discriminate between stable and failed TJRs, as its predictive value was not statistically proven. However, it is generally thought that hypersensitivity testing should be performed in patients with a history of metal allergy and in failed TJRs, especially with metal-on-metal implants and when the cause of the loosening is doubtful.
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Affiliation(s)
- D Granchi
- Rizzoli Orthopaedic Institute, Laboratory for Orthopaedic Pathophysiology and Regenerative Medicine, Via di Barbiano 1/10, 40136 Bologna, Italy.
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Schalock PC, Menné T, Johansen JD, Taylor JS, Maibach HI, Lidén C, Bruze M, Thyssen JP. Hypersensitivity reactions to metallic implants - diagnostic algorithm and suggested patch test series for clinical use. Contact Dermatitis 2011; 66:4-19. [PMID: 21957996 DOI: 10.1111/j.1600-0536.2011.01971.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cutaneous and systemic hypersensitivity reactions to implanted metals are challenging to evaluate and treat. Although they are uncommon, they do exist, and require appropriate and complete evaluation. This review summarizes the evidence regarding evaluation tools, especially patch and lymphocyte transformation tests, for hypersensitivity reactions to implanted metal devices. Patch test evaluation is the gold standard for metal hypersensitivity, although the results may be subjective. Regarding pre-implant testing, those patients with a reported history of metal dermatitis should be evaluated by patch testing. Those without a history of dermatitis should not be tested unless considerable concern exists. Regarding post-implant testing, a subset of patients with metal hypersensitivity may develop cutaneous or systemic reactions to implanted metals following implant. For symptomatic patients, a diagnostic algorithm to guide the selection of screening allergen series for patch testing is provided. At a minimum, an extended baseline screening series and metal screening is necessary. Static and dynamic orthopaedic implants, intravascular stent devices, implanted defibrillators and dental and gynaecological devices are considered. Basic management suggestions are provided. Our goal is to provide a comprehensive reference for use by those evaluating suspected cutaneous and systemic metal hypersensitivity reactions.
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Affiliation(s)
- Peter C Schalock
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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12
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Cousen PJ, Gawkrodger DJ. Metal allergy and second-generation metal-on-metal arthroplasties. Contact Dermatitis 2011; 66:55-62. [DOI: 10.1111/j.1600-0536.2011.01970.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Thyssen JP. Nickel and cobalt allergy before and after nickel regulation - evaluation of a public health intervention. Contact Dermatitis 2011; 65 Suppl 1:1-68. [DOI: 10.1111/j.1600-0536.2011.01957.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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14
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Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and systemic hypersensitivity reactions to metallic implants. Dermatitis 2011. [PMID: 21504692 DOI: 10.2310/6620.2011.10055] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cutaneous reactions to metal implants, orthopedic or otherwise, are well documented in the literature. The first case of a dermatitis reaction over a stainless steel fracture plate was described in 1966. Most skin reactions are eczematous and allergic in nature, although urticarial, bullous, and vasculitic eruptions may occur. Also, more complex immune reactions may develop around the implants, resulting in pain, inflammation, and loosening. Nickel, cobalt, and chromium are the three most common metals that elicit both cutaneous and extracutaneous allergic reactions from chronic internal exposure. However, other metal ions as well as bone cement components can cause such hypersensitivity reactions. To complicate things, patients may also develop delayed-type hypersensitivity reactions to metals (ie, in-stent restenosis, prosthesis loosening, inflammation, pain, or allergic contact dermatitis) following the insertion of intravascular stents, dental implants, cardiac pacemakers, or implanted gynecologic devices. Despite repeated attempts by researchers and clinicians to further understand this difficult area of medicine, the association between metal sensitivity and cutaneous allergic reactions remains to be fully understood. This review provides an update of the current knowledge in this field and should be valuable to health care providers who manage patients with conditions related to this field.
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Thyssen JP, Menné T, Schalock PC, Taylor JS, Maibach HI. Pragmatic approach to the clinical work-up of patients with putative allergic disease to metallic orthopaedic implants before and after surgery. Br J Dermatol 2011; 164:473-8. [PMID: 21087227 DOI: 10.1111/j.1365-2133.2010.10144.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Allergic complications following insertion of metallic orthopaedic implants include allergic dermatitis reactions but also extracutaneous complications. As metal-allergic patients and/or surgeons may ask dermatologists and allergologists for advice prior to planned orthopaedic implant surgery, and as surgeons may refer patients with complications following total joint arthroplasty for diagnostic work-up, there is a continuous need for updated guidelines. This review presents published evidence for patch testing prior to surgery and proposes tentative diagnostic criteria which clinicians can rely on in the work-up of patients with putative allergic complications following surgery. Few studies have investigated whether subjects with metal contact allergy have increased risk of developing complications following orthopaedic implant insertion. Metal allergy might in a minority increase the risk of complications caused by a delayed-type hypersensitivity reaction. At present, we do not know how to identify the subgroups of metal contact allergic patients with a potentially increased risk of complications following insertion of a metal implant. We recommend that clinicians should refrain from routine patch testing prior to surgery unless the patient has already had implant surgery with complications suspected to be allergic or has a history of clinical metal intolerance of sufficient magnitude to be of concern to the patient or a health provider. The clinical work-up of a patient suspected of having an allergic reaction to a metal implant should include patch testing and possibly in vitro testing. We propose diagnostic criteria for allergic dermatitis reactions as well as noneczematous complications caused by metal implants.
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Affiliation(s)
- J P Thyssen
- Department of Dermato-Allergology, National Allergy Research Centre, Copenhagen University Hospital Gentofte, Hellerup, Denmark.
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Thyssen JP, Engkilde K, Menné T, Johansen JD, Hansen PR, Gislason GH. No association between metal allergy and cardiac in-stent restenosis in patients with dermatitis-results from a linkage study. Contact Dermatitis 2011; 64:138-41. [DOI: 10.1111/j.1600-0536.2010.01857.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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