Tissue reaction and metal sensitivity. An animal study

The Inflammatory Effects of Breast Implant Particulate Shedding: Comparison With Orthopedic Implants

Currently, there is a dearth of information regarding the degree of particle shedding from breast implants (BIs) and what are the general biological consequences of BI debris. Thus, it is unclear to what degree BI debris compromises the long-term biological performance of BIs. For orthopedic implants, it is well established that the severity of biological reactivity to implant debris governs long-term clinical performance. Orthopedic implant particulate debris is generally in the range of 0.01 to 100 μm in diameter. Implant debris-induced bioreactivity/inflammation is mostly a peri-implant phenomenon caused by local innate immune cells (eg, macrophages) that produce proinflammatory cytokines such as tumor necrosis factor-α, interleukin-1β, interleukin-6, and prostaglandin 2 (PGE2). In orthopedics, there have been few systemic concerns associated with polymeric implant debris (like silicone) other than documented dissemination to remote organs (eg, liver, spleen, etc.) with no known associated pathogenicity. This is not true of metal implant debris where normal (well-functioning) implants can induce systemic reactions such as delayed type hypersensitivity. Diagnostic analysis of orthopedic tissues has focused on innate (macrophage mediated) and adaptive (lymphocyte-mediated hypersensitivity) immune responses. Orthopedic implant debris-associated lymphocyte cancers have not been reported in over 40 years of orthopedic literature. Adaptive immune responses such as hypersensitivity reactions to orthopedic implant debris have been dominated by certain implant types that produce specific kinds of debris (eg, metal-on-metal total joint prostheses). Orthopedic hypersensitivity responses and atypical BI bioreactivity such as BI-associated anaplastic large cell lymphoma share crossover markers for diagnosis. Differentiating normal innate immune reactivity to particles from anaplastic large cell lymphoma reactions from delayed type hypersensitivity reactions to BI-associated implant debris remains unclear but vital to patients and surgeons.

Metal sensitivity after TKA presenting with systemic dermatitis and hair loss

Recent problems with metal-on-metal bearings in total hip arthroplasty have highlighted a connection between metal particles and allergic responses. Metal sensitivity associated with total knee arthroplasty (TKA) is less understood and poorly characterized. However, metal sensitivity can lead to TKA failure. Accurate and reliable testing for this phenomenon is elusive; therefore, the diagnosis of metal sensitivity remains one of exclusion. Only skin testing and lymphocyte transformation testing are commonly available to assess hypersensitivity, and neither test is reliable.This article describes a woman who presented with severe whole-body dermatitis and hair loss. After prolonged pain and progressive stiffness, including failed manipulation while under anesthesia and open synovectomy, the patient had a positive skin test, but the lymphocyte transformation test was negative. She was treated for metal sensitivity with TKA revision to nonallergenic components, and all symptoms resolved. One year after revision, she had good range of motion, complete dermatitis resolution, and hair loss restoration.To the authors' knowledge, this is the only report that describes hair loss as a symptom of metal sensitivity secondary to TKA and hair regrowth after revision. The authors now include metal sensitivity in a differential of causes of pain and other unusual symptoms after TKA that are otherwise unexplained.

Tissue reaction to the nickel implants in the guinea pigs

OBJECTIVES

The aim of the study was the assessment of local tolerance to nickel implants during 9 months observation in guinea pigs sensitized to nickel before implantation and non-sensitized ones.

MATERIALS AND METHODS

Three groups of guinea pigs were included in the study: 10 sensitized to nickel by the guinea pig maximization test; 10 previously non-sensitized and 10 in control group. In 20 animals (except control group) the nickel implants were inserted in the muscle of the back. After 9 months of observation, the animals were patch-tested with 5% nickel sulfate. Also percentage of eosinophils in peripheral blood was examined. Next, the tissue surrounding the implant and skin from the area of patch tests were collected for the histological examination.

RESULTS

In 70% of previously sensitized animals, the patch test confirmed the sensitivity to nickel. In 60% of previously non-sensitized animals, a positive reaction to nickel occurred. The results of patch tests in control group were negative. Percentage of eosinophils in peripheral blood was fourfold higher in animals sensitized to nickel than in control group. In histological examination, in the tissue surrounding the implant a dissimilarity concerning the intensity of cellular infiltration was observed between animals previously allergic and non-allergic to nickel. In the 2 of 10 previously sensitized guinea pigs quite severe inflammatory reactions in the inside of connective tissue capsule were noted which may indicate a local allergic reaction. The histological images of skin collected from the positive patch test site corresponded with the typical allergic contact dermatitis.

CONCLUSIONS

Nickel implants may cause primary sensitization to nickel. The nature of the histological changes in the tissues around the implants in guinea pigs sensitized to nickel may correspond to an allergic reaction. The examination of percentage of eosinophils in blood of guinea pigs may be useful in assessing the allergenic activity of metal alloys containing nickel.

Infection or allergy in the painful metal-on-metal total hip arthroplasty?

Metal-on-metal articulations are increasingly used in total hip arthroplasty. Patients can be sensitive to metal ions produced by the articulation and present with pain or early loosening. Infection must be excluded. Correct diagnosis before revision surgery is crucial to implant selection and operation planning. There is no practical guide in the literature on how to differentiate between allergy and infection in a painful total hip arthroplasty. We present the history, clinical findings and hip scores, radiology, serology, hip arthroscopy and aspirate results, labeled white cell scan, revision-hip findings, histology and clinical results of a typical patient with a hypersensitivity response to a metal-on-metal hip articulation, and how results differ from patients with an infected implant. A practical scheme to investigate patients with a possible hypersensitivity response to an implant is presented.

A review of the biologic effects of spine implant debris: Fact from fiction

BACKGROUND

Biologic-reactivity to implant-debris is the primary determinant of long-term clinical performance. The following reviews: 1) the physical aspects of spinal-implant debris and 2) the local and systemic biologic responses to implant debris.

METHODS

Methods included are: 1) gravimetric wear analysis; 2) SEM and LALLS; 3) metal-ion analysis; 4) ELISA, toxicity testing, patch testing; and 5) metal-lymphocyte transformation testing (metal-LTT).

RESULTS

Wear and corrosion of spine-implants produce particles and ions. Particles (0.01-1000 μm) are generally submicron ( <1 µm). Wear rates of metal-on-polymer and metal-on-metal disc arthroplasties are approximately 2-20 and 1 mm(3)/yr, respectively. Metal-on-metal total disc replacement components have significant increases in circulating metal (less than 10-fold that of controls at 4 ppb-Co and 3 ppb-Cr or ng/mL). Debris reactivity is local and systemic. Local inflammation is caused primarily by ingestion of debris by local macrophages, which produce pro-inflammatory cytokines TNFα, IL-1β, IL-6, and PGE2. Systemic responses associated with implant-debris have been limited to hypersensitivity reactions. Elevated amounts of in the liver, spleen, etc of patients with failed TJA have not been associated with remote toxicological or carcinogenic pathology to date. Implant debris are differentially bioreactive. Greater numbers are pro-inflammatory; the smaller-sized debris are more bioreactive by virtue of their greater numbers (dose) for a given amount of implant mass loss (one 100-μm-diameter particle is equivalent in mass to 1 million 1-μm-diameter particles). Elongated particles are pro-inflammatory (ie, aspect ratio of greater than 3). Metal particles are more proinflammatory than polymers, ceteris paribus.

CONCLUSION

Spinal arthroplasty designs have been in use for more than 20 years internationally; therefore, concerns about neuropathology, toxicity, and carcinogenicity are mitigated. Debris-induced inflammation still depends on the individual and the type of debris. The consequence of debris-induced inflammation is continued; vigilance by physicians is recommended monitoring of spinal implants using physical exams and testing of metal content and bioreactivity, as is planning for the likelihood of revision in younger individuals.

Lymphocyte responses in patients with total hip arthroplasty

How lymphocyte-mediated metal sensitivity affects orthopaedic implant performance remains poorly understood. Do patients with implants exhibit elevated lymphocyte reactivity to metals and is this reactivity more generalized or more implant-alloy specific? We investigated these questions by measuring lymphocyte responses to implant metals (Cr(+3), Co(+2), Ni(+2) at 0.1mM, and Ti(+4) at 0.001 mM) in six subject groups: Group 1a=young controls, Group 1b=age matched controls, Group 2a=subjects with osteoarthritis (OA) and no history of metal sensitivity, Group 2b=OA subjects with history of metal sensitivity, Group 3a=total hip arthroplasty (THA) subjects with no to mild radiographic osteolysis, and Group 3b=THA subjects with moderate osteolysis. Lymphocyte proliferation, using Lymphocyte Transformation Testing (LTT), and cytokine release provided quantitative reactivity measurement, where a stimulation index of >2 indicated metal sensitivity. OA subjects with a history of metal sensitivity (Group 2b) were more metal reactive to Ni than any other group, as expected (66% incidence and Stimulation Index >20). However, THA subjects (Groups 3a and b) were >3 fold more reactive to Cr (p<0.04), than were controls (Groups 1a & b) or OA subjects (Groups 2a & b). THA subjects with moderate vs mild osteolysis (Group 3b vs 3a) were more reactive to Co (43% vs 0% incidence). Only osteolytic THA subjects demonstrated increased cytokine responses with >two-fold (p<0.05) increases in soluble interferon-gamma (IFN-gamma) and interleukin-2 (IL-2) levels in response to Cr challenge. This elevated incidence and averaged level of lymphocyte reactivity supports a metal-specific adaptive immune response and suggests involvement in the pathogenesis of poor implant performance, e.g. aseptic osteolysis.

Spinal fixation device: a 6-year postimplantation study

Long-term tissue response to a metal device is described here. The components of a spinal fixation device were removed 6 years after implantation, following the need for revision surgery after a fall. Scanning electron microscopy (SEM) revealed changes in surface topography of the metal. Examination of the adjacent tissue showed a chronic inflammatory response with occasional metal debris. Immunohistochemistry identified the predominant macrophages and abundant neovascularization. The presence of macrophages in tissues adjacent to the implants, in an otherwise asymptomatic person, is noteworthy.

Immunobiologic consequences of assist devices

The aberrant state of monocyte and T-cell activation resulting from these host-device interaction is accompanied by two parallel processes: (1) selective loss of Th1 cytokine-producing CD4 T cells through activation-induced cell death, and (2) unopposed activation of Th2 cytokine-producing CD4 T cells resulting in B-cell hyperreactivity and dysregulated immunoglobulin synthesis via Th2 cytokines and heightened CD40 ligand-CD40 interactions. The net result of these events is that on one hand the VAD recipient develops progressive defects in cellular immunity and is at increased risk of serious infection, and on the other hand the VAD recipient is more likely to develop allosensitization, posing a significant risk to successful transplant outcome.

Differential lymphocyte reactivity to serum-derived metal-protein complexes produced from cobalt-based and titanium-based implant alloy degradation

The lymphocyte response to serum protein complexed with metal from implant alloy degradation was investigated in this in vitro study using primary human lymphocytes from healthy volunteers (n = 10). Cobalt chromium molybdenum alloy (Co-Cr-Mo, ASTM F-75) and titanium alloy (Ti-6Al-4V, ASTM F-136) beads (70 microm) were incubated in agitated human serum at 37 degrees C to simulate naturally occurring metal implant alloy degradation processes. Particulate free serum samples that had been incubated with metal were then separated into molecular weight based fractions. The amounts of soluble Cr and Ti within each serum fraction were measured and correlated with lymphocyte proliferation response to the individual serum fractions. Lymphocytes from each subject were cultured with 11 autologous molecular weight based serum fractions either with or without added metal. Two molecular weight ranges of human serum proteins were associated with the binding of Cr and Ti from Co-Cr-Mo and Ti implant alloy degradation (at <30 and 180-250 kDa). High molecular weight serum proteins ( approximately 180 kDa) demonstrated greater lymphocyte reactivity when complexed with Cr alloy and Ti alloy than low (5-30 kDa) and midrange (30-77 kDa) serum proteins. When the amount of lymphocyte stimulation was normalized to both the moles of metal and the moles of protein within each fraction (metal-protein complex reactivity index), Cr from Co-Cr-Mo alloy degradation demonstrated approximately 10-fold greater reactivity than Ti in the higher molecular weight serum proteins ( approximately 180 kDa). This in vitro study demonstrated a lymphocyte proliferative response to both Co-Cr-Mo and Ti alloy metalloprotein degradation products. This response was greatest when the metals were complexed with high molecular weight proteins, and with metal-protein complexes formed from Co-Cr-Mo alloy degradation.

Metal sensitivity in patients with orthopaedic implants

All metals in contact with biological systems undergo corrosion. This electrochemical process leads to the formation of metal ions, which may activate the immune system by forming complexes with endogenous proteins. Implant degradation products have been shown to be associated with dermatitis, urticaria, and vasculitis. If cutaneous signs of an allergic response appear after implantation of a metal device, metal sensitivity should be considered. Currently, there is no generally accepted test for the clinical determination of metal hypersensitivity to implanted devices. The prevalence of dermal sensitivity in patients with a joint replacement device, particularly those with a failed implant, is substantially higher than that in the general population. Until the roles of delayed hypersensitivity and humoral immune responses to metallic orthopaedic implants are more clearly defined, the risk to patients may be considered minimal. It is currently unclear whether metal sensitivity is a contributing factor to implant failure.

A triple assay technique for the evaluation of metal-induced, delayed-type hypersensitivity responses in patients with or receiving total joint arthroplasty

The determination of biocompatibility has been dominated historically by the characterization of candidate materials based upon the observation of adverse host responses. However, some adverse responses are subtle in clinical settings and continue to foster debate and investigation. One of these responses is "metal allergy" or hypersensitivity to metallic biomaterials. Current methods used to diagnose hypersensitivity reactions, such as dermal patch testing and migration inhibition assays, are not well accepted in orthopedic practice as a means for the characterization of hypersensitivity to metallic joint-replacement components. An increasing need to resolve whether metal sensitivity may be a significant and/or predisposing factor for eliciting an over-aggressive immune response in patients with metallic implant components requires improved and standardized widespread study. Here we present three in vitro methodologies: (1) a proliferation assay, (2) cytokine analysis using ELISA, and (3) a migration inhibition assay. When in conjunction with one another, these assays may be used to more comprehensively quantify metal-induced hypersensitivity responses. Therefore, these methodologies are detailed with the intent of facilitating multi-center large-scale studies. In the following cases, a multi-assay approach for measuring the prevalence of delayed-type hypersensitivity in orthopedic patients shows the propensity to yield a more comprehensive and, therefore, more conclusive determination than currently employed patch testing or single assay techniques.

Hypersensitivity to metallic biomaterials: a review of leukocyte migration inhibition assays

Metal hypersensitivity is a well-established phenomenon occurring in a variety of domestic and workplace settings. Degradation products of metallic biomaterials may mediate metal hypersensitivity. However, little is known about the short- and long-term pharmacodynamics and bioavailability of circulating metal degradation products in vivo. Mechanisms by which in vivo metal sensitivity reactions occur have not been well characterized and the degree to which metal sensitivity may be a predisposing factor for eliciting an overaggressive immune response remains clinically unpredictable. In vitro leukocyte migration inhibition assays have been used for investigating cell-mediated hypersensitivity reactions to biomaterial and biomaterial degradation products. This review provides a historical and technical summary of four in vitro techniques used for determination of leukocyte migration activity: (1) membrane migration or Boyden chamber, (2) capillary tube, (3) leukocyte migration using agarose technique, and (4) collagen gels. It is difficult to determine which, if any, of these techniques is singularly best suited for the investigation of suspected biomaterial-related symptoms in patients. However, Boyden chamber membrane migration testing is recommended for clinical investigations, principally because a high degree of standardized investigator independent materials and methodologies is necessary for compiling and comparing the results of patients tested at various times over the length of an extended study. Ultimately, in vitro migration inhibition testing has the potential to provide a reliable means for predicting some complications and thus enhancing the outcome for patients receiving metallic implants. Continuing improvements in migration inhibition testing methods, used alone or in combination with other immunologic assays, will likely improve assessment of patients susceptible to biomaterial antigen-induced delayed-type hypersensitivity responses.

Distribution of cobalt chromium wear and corrosion products and biologic reactions

Replacement hip arthroplasty with the use of ultrahigh molecular weight polyethylene for the cup articulating with a metal head has provided a low friction arthroplasty with years of success. However, the search for improved materials and designs for articulating surfaces continues. The use of metallic heads articulating with metallic cups is now being reconsidered for total hip replacements. Success will be enhanced if wear and corrosion of the articulating surfaces can be kept below that of the metal on ultrahigh molecular weight polyethylene couple. Concern has been raised about the release, and biologic fate, of metal species from corrosion and wear. Titanium alloys have been shown to have limitations as an articulating surface showing significant wear, and the alloy per se should not be considered for wear couples in total hip replacements. The cobalt chromium alloys are known to have reasonable wear and corrosion properties and continue to be evaluated. The issue of cobalt chromium wear and corrosion products and how this relates to the biologic performance of total hip replacement devices is reviewed. Under the condition of wear as currently experienced at the articulating surfaces of cobalt chromium alloys and ultrahigh molecular weight polyethylene, the amount of metallic products transferred to the tissues is sufficiently low to be well tolerated by the biologic system. Nickel and cobalt ions arc, rapidly transported from the implant site and eliminated in the urine. Chromium is stored in the tissue and eliminated more slowly. The issue of host hypersensitivity to these elements remains of concern. All 3 elements, in ionic form, are known to cause contact dermatitis. Untoward biologic reactions, including hypersensitivity, should be minimized if wear and corrosion phenomena are minimized.

Biologic effects of cobalt chrome in cell and animal models

The literature on animal and cellular models used to study the response to cobalt chrome alloy implants and wear and corrosion products is reviewed. Animal studies show that in solid form cobalt chrome alloy is relatively well tolerated. Injections of large numbers of particles in a single bolus lead to acute inflammation and necrosis, followed by a chronic inflammatory response. Macrophages are the predominant cell type and may persist in the tissues for years. Long term studies have failed to confirm the induction of tumors. In vitro studies confirm the toxic effects of cobalt chrome alloy corrosion products and wear particles, especially cobalt, and show that intracellular corrosion is an important mechanism for early release of cobalt ions. In vitro studies show that cobalt chrome alloy particles induce the release of inflammatory mediators from macrophages before causing cell death. These mediators have significant effects on osteoblastlike cells, as well as inducing bone resorption. Variations in the cell types, implantation site, and characteristics of the particles used in experimental models make interpretation of the results difficult. Standardized methods to control for size, shape, and number of particles for testing are proposed. It is important that in vitro and in vivo findings not be taken in isolation, but be compared with the results of human studies.

Production of monoclonal antibodies to study corrosion products of CO-CR biomaterials

Sensitivity to nickel, cobalt, and chromium is common among the general population. The identification of these sensitivities is generally by the detection of cell-mediated immunity. We have reported previously the use of an indirect enzyme-linked immunosorbent assay method to quantitate metal-specific antibodies in patients with total joint replacements. To study the haptenic potential of these metal ions, rabbit albumin-glutathione-metal complexes with chromium, cobalt, or nickel were injected into mice. The splenocytes from one mouse in each group which developed a strong antibody against GSH-metal complexes were isolated and fused with myeloma cells to produce monoclonal antibodies. Chromium, cobalt, and nickel antibodies had similar affinity and bound with the specific GSH-metal complex. There was very little cross-reactivity between these antibodies. An inhibition assay using these monoclonal antibodies was demonstrated to be a simple technique, suitable for quantitation of free metal in solution.

Detection of antibodies against corrosion products in patients after Co-Cr total joint replacements

Sensitivity to nickel, cobalt, and chromium is common among the general population. The identification of these sensitivities is generally by the detection of cell-mediated immunity. Detection of humoral immunity to these metals has rarely been undertaken because suitable assays are not available. To further our knowledge about the systemic humoral immune system response to weak hapten-syngeneic or allogeneic protein conjugates (corrosion and wear products of metallic orthopedic devices), a sensitive enzyme-linked immunosorbent assay (ELISA) method for testing for antibody (humoral immunity) to metals was developed. Microtiter plates were coated with human serum albumin (HSA) or glutathione (GSH) and then conjugated with metal ions. Plates coated with HSA or GSH and without metal ions served as background controls. An indirect ELISA method was used to detect antibody binding. Patients bearing cobalt-chromium alloy devices were considered to be the most likely candidates as sources of antibody to metal and were used to document the usefulness of the test. Specificity of the test was documented by inhibition studies with these metal ions in the ELISA assay. The serum samples of 10 patients were screened for the presence of Cr-, Co-, or Ni-specific antibody at various periods up to 5.5 years after implantation of F-75 cobalt alloy total joint replacements. All patients had implants that were functioning well. The pre- and postimplantation humoral immune profiles of patients were determined and compared with each preimplantation control and with a pooled normal serum sample. This study presents evidence that metal-protein complex-specific antibodies can be detected. The clinical implications remain to be determined.

Long-term durability of the interface in FRP composites after exposure to simulated physiologic saline environments

Fiber/matrix interfacial bond strength significantly influences the mechanical behavior of fiber-reinforced polymer (FRP) composites. Interfacial bond strength durability is therefore particularly important in the development of FRP composites for implant applications where diffused moisture may potentially weaken the material over time. In this study, the long-term durability of interfacial bonding in carbon fiber/380 grade polyetheretherketone (C/PEEK) and carbon fiber/polysulfone (C/PSF) composites was investigated after exposure to hygrothermal environments. A single fiber pull-out test was used to quantitatively determine the ultimate bond strength (UBS) of the samples following exposure. Samples were tested at three temperatures (37, 65, and 95 degrees C) for six time periods (0-5000 h) and in two environments (dry and physiologic saline-immersed). A mathematical model based on nth order chemical reaction kinetics was applied to describe the long-term durability of the interface. The results of this study indicate that interfacial bond strengths in C/PSF and C/PEEK (380 grade) composites are significantly decreased by exposure to physiologic saline and are functions of both time and temperature. For each material, the kinetics of degradation analysis predicts further bond strength losses following initial saturation, which then stabilizes at temperature-dependent equilibrium bond strength levels.

Lag screws in sagittal split osteotomies: should they be removed?

The use of stainless steel lag screws to provide rigid internal fixation for sagittal split osteotomies was first described more than 17 years ago. It was shown that the need for intermaxillary fixation could be eliminated and that lower relapse rates could be produced. However a decade later, removal of the screws was still being advocated. In this study, 48 patients had a total of 259 screws inserted over a 5 year period. Twenty six screws were removed 10 months following insertion. Most of these were removed in the absence of any symptoms although a few were palpable or tender to touch. None of the screws removed were loose nor was there any evidence of infection or corrosion associated with them. The long term consequences of screw retention are discussed and it is suggested that they do not need to be removed routinely.

The lymphocyte response to nickel salt in patients with orthopedic implants

In this pilot study, 14 patients with different symptoms and signs in relation to orthopedic implants were compared with 12 asymptomatic patients to determine the in vitro lymphocyte response to nickel sulfate. We conclude that nickel allergy may explain some, but not most, of the local and generalized symptoms associated with orthopedic implants.

Tissue reactions to implanted orthodontic wires in rabbits

Tissue response to a Fe-Cr-Ni and a Co-Cr-Ni orthodontic wire, in the as-received state and with silver soldered joints, was investigated. Specimens with polytetrafluoroethylene (PTFE) as a reference material were implanted in the subcutaneous tissue of rabbits. Six rabbits were sensitized to nickel, four animals were sham-sensitized, and two were left untreated. The results showed that the as-received wires gave no tissue response relative to the PTFE control. In soldered specimens that were moderate to extreme reactions adjacent to the soldered joint and around the wire portion as well. The soldered Co-Cr-Ni wire elicited the most severe reactions, most pronounced in the nickel-sensitized animals. The agar overlay cell culture test of some retrieved implants showed pronounced cytotoxicity of the soldered specimens. Leachable toxic components of the silver solder seemed to be of major importance in the observed cell culture and tissue response to the soldered specimens.

Experimental sensitization of guinea-pigs to nickel and patch testing with metal samples

Two groups each of 30 guinea-pigs were painted on 5 days/wk for 4 wk with 1% nickel sulphate in lanolin. The dose was applied to the shaved dorsal skin, which was prepared daily before treatment with sodium lauryl sulphate and injected intradermally each week during this period with 0.1 ml 1% potassium alum in distilled water, close to the site of NiSO4 application. Of the two groups of guinea-pigs submitted to this epicutaneous procedure, 63 and 80% developed skin allergy in response to challenge with 2% NiSO4 after a rest period of 2 wk, whereas no sensitization response was elicited by 1% NiSO4 in the guinea-pig maximization test. When two further groups were sensitized by the epicutaneous procedure, the first group, with a sensitization rate of 52% at the first challenge, showed no decline in response with five successive monthly challenges. Addition of NiCl2 to the drinking-water of the second group did not increase the sensitization rate induced by the monthly rechallenges with NiSO4. In guinea-pigs allergic to nickel, plating of Ni-coated brass discs with chromium as a special surface treatment prevented the occurrence of the contact allergy elicited by brass discs coated with Ni alone, whereas plating with gold/copper/cadmium did not.

Apparent absence of local response to bone screws in guinea pigs with contact sensitivity

Guinea pigs sensitized to nickel, cobalt, or chromium were used to study if impaired fixation occurred as a result of allergy against metal implants in bone. Screws made from stainless-steel (ASTM F55, F138-139) or cobalt chromium (ASTM F75-76) were inserted in the right and left proximal tibiae, and the mechanical strength of the fixation to the bone was evaluated after 4 months. In addition, we studied the histology on decalcified sections of the implant bone interface from the distal femur where the same type of screws had been inserted. To see if changes in bone density occurred in the proximal tibia as a result of allergy, the amount of ash was determined. Although the animals maintained their contact sensitivity throughout the experimental period, there were no differences between allergic and control animals for any of the parameters studied. All screws were well fixed in the tibia at the end of the experiment, and histologically we did not find any significant differences between allergic and control animals by qualitative examination. The experiment supports our earlier results from a 6-week experiment and indicates that contact allergy may be unimportant for the fate of orthopedic implants.

The binding of metal salts and corrosion products to cells and proteins in vitro

The binding of metal ions from salts and from corrosion products of 316 LVM stainless steel and MP-35 to blood cells and serum proteins was studied in vitro. In the first series of experiments, metal salts were added to whole blood and then the blood separated into red cells, white cells, and serum. Nickel from nickel chloride or corrosion products of stainless steel bound in very small quantities to blood cells. Cobalt from cobalt chloride bound to both red cells and white cells. Chromium from chromic chloride (Cr3+) bound to cells in very small quantities whereas chromium from potassium dichromate (Cr6+) and corrosion products showed very high to binding to red cells and some binding to white cells. In a second series of experiments the blood was separated into its components and then the metal salts were added and the binding pattern was identical. In a third series of experiments serum which had interacted with the metal salts or corrosion products was separated into its components by isoelectric focusing on polyacrylamide gels. Almost all of the metal, whatever the source, was detected in the albumin region of the gels indicating strong binding to albumin. These studies on the cell and protein binding of the metals help to explain the dissemination of corrosion products from the site of the implant and subsequent systemic responses by some individuals.

Attempts to induce contact allergy to nickel in the mouse

Various attempts to sensitize mice to nickel salts are described. The antigen was applied once or repeatedly by the epicutaneous or intracutaneous route and by combinations of the two. The procedures included prior irritation of the skin, treatment with Freund's complete adjuvant, cyclophosphamide or Tetramisol, and prior sensitization to picryl chloride. Contact allergy was achieved only by repeated epicutaneous application of a strong nickel solution over a 3-week period. The resulting dermatitis was demonstrated by a weak but significant wet weight increase of inflamed skin.

Role of medical materials, both in implant and surface applications, in immune response and in resistance to infection

The term biocompatibility encompasses many aspects of the behaviour of a material in the body including its effects on the host and the host's effects on it. Two aspects of biocompatibility which are difficult to predict are sensitivity reactions and infections. These reactions are very dependent on the host and other factors beyond the control of the testing laboratory. Much of the information on the problems of sensitivity reactions and infection rates in the actual use of the biomaterials and devices comes from case reports in the literature. This article will focus on review papers and a synthesis of reports and does not contain a thorough citation of the literature.

Tissue response to allergenic leachables from dental materials

In addition to toxic reactions to dental materials, some individuals may develop or exhibit hypersensitivity reactions to leachable components. An experimental model combining the guinea pig maximization test for induction of hypersensitivity and the subcutaneous implantation of dental cements is described. Guinea pigs immunized with AH 26, an epoxy-bisphenol resin, showed an increased tissue response to AH26 implants. Guinea pigs immunized with zinc oxide-eugenol did not show a similarly increased response, possibly because of an anti-inflammatory effect of eugenol. The experimental model may prove useful in predicting the effect of leachable allergens from dental materials in sensitized individuals.

Metal allergy, metal implants and fracture healing

The rabbit tibia was used as a model to study the effects of metal sensitivity reactions on the healing of fractures. Animals were injected with nickel chloride in Freund's complete adjuvant to cause sensitivity, and fractures were stabilized with 316L stainless steel intramedullary rods and followed for 16 weeks. A control group received no injections. The response was evaluated biomechanically with torsional testing at sacrifice, radiologically by examining the roentgenograms for evidence of loosening, and histologically. The results demonstrated a slight decrease in strength, a moderate increase in resorption and a significant decrease in cellularity and new bone formation in the sensitive animals as compared to control. These results are consistent with a reaction of comparatively short duration.

[Allergy to metal following osteosynthesis]

Corrosions of metallic implants can lead to demonstrable accumulation of implant-specific metals in the tissue surrounding the implant. This can give rise to metal sensitization after activation of cellular immune mechanism of the body. A connection between metal sensitization and bone infection morbidity after insertion of metallic implants is thus conceivable. In our investigations to clarify this question, we were able to obtain the following results using the leukocyte migration inhibition test for cobalt, chromium and nickel on various investigation groups after statistical analysis: 1. Patients bearing metallic implants without infection show the same rate of metal allergy as persons without implants. 2. Patients bearing metallic implants with infection show an increased rate of allergy to cobalt and nickel compared to persons without implants and to patients bearing metallic implants without infection. They are sensitive to one of the three tested metals more than twice as frequently as patients with aseptic osteosynthesis. Furthermore, this study has addressed the question of causality: Does metal allergy cause an inflammatory reaction or does infection cause sensitization, e.g. via increased corrosion of metallic implants following infection.

Screw fixation in bone of guinea pigs sensitized to nickel and cobalt

A screw was inserted transversely through the distal femora and proximal tibiae of guinea pigs sensitized to either Ni or Co. An equal number of nonsensitized animals were treated in the same way. The animals with Ni allergy received an ASIF stainless steel screw and the animals with Co allergy a Howmedica Vitallium screw. After 6 weeks no obvious differences were observed in the histological picture around the femur screws that could be ascribed to metal sensitivity. The mechanical strength of the bone adjacent to the tibial screws was tested by measuring maximum torque during continuous tightening of the screws at a rate of 2 revolution/second. No significant differences in maximum torque resistance were found between sensitized and nonsensitized animals. The results indicate that sensitivity to Ni or Co does not compromise the mechanical fixation between metal and bone during the early period after the implantation.

In vivo and in vitro considerations of corrosion testing

In vitro experiments were conducted in which the fretting corrosion rate of stainless steel plates and screws in 0.9% saline was compared with the rate in solutions of 10% calf serum in saline. The results demonstrated a ten-fold decrease in the fretting corrosion rate with the addition of serum to saline. However, it also demonstrated that the lower concentration of nickel in the serum solutions was more biologically active than the higher concentration in saline when the solutions were used to skin test rabbits made allergic to nickel by injection.