Patient Self-Reported Allergies and Their Correlation with Thoracic Outlet Syndrome Outcomes

OBJECTIVES

Thoracic outlet syndrome (TOS) is an uncommon neurovascular disorder that presents as neck and upper extremity pain secondary to brachial plexus trunk or subclavian vasculature compression. The orthopedic literature has correlated patient-reported allergies to postoperative patient-reported outcome (PRO) scores for a variety of surgical procedures. We sought to evaluate patient-reported allergies and PROs following surgical decompression for TOS.

METHODS

A chart review was conducted after identifying patients who underwent surgical thoracic outlet decompression by a single surgeon. Patients were contacted and administered five PRO questionnaires via telephone: the QuickDASH Outcome Measure questionnaire (disabilities of the arm, shoulder, and hand [DASH]), the Cervical Brachial Symptom Questionnaire, the Single Assessment Numeric Evaluation, the 12-Item Short Form Survey, and the Numeric Rating Scale (a visual analogue scale). A bivariate analysis of Pearson's correlation coefficient (r) was used to determine the associations of allergies with questionnaires and demographic variables.

RESULTS

Of the 393 patients (128 males and 265 females) identified in the study, 75 (24%) responded and completed all of the questionnaires, 18 (24%) males and 57 (76%) females. A significant correlation was found between the number of allergies reported and the QuickDASH Outcome Measure questionnaire (r = 0.375, P < 0.001), the Cervical Brachial Symptom Questionnaire (r = 0.295, P = 0.01), change in the Single Assessment Numeric Evaluation score (r = -0.310, P < 0.01), change in the visual analogue scale (r = 0.244, P = 0.035), sex (r = 0.245, P = 0.034), and the number of medications (r = 0.642, P < 0.001).

CONCLUSIONS

The increased frequency of patient-reported allergies is significantly associated with worse PRO scores for women undergoing TOS surgical decompression. Better understanding this association can help physicians counsel patients on expected outcomes.

Do Patients With Hypoallergenic Total Knee Arthroplasty Implants for Metal Allergy Do Worse? An Analysis of Health Care Utilizations and Patient-Reported Outcome Measures

BACKGROUND

Metal allergy is a rare and controversial cause of implant failure and poor outcomes following total knee arthroplasty (TKA). Few studies have investigated clinical and patient-reported outcome measures (PROMs) in patients treated with hypoallergenic implants. This investigation aimed to compare: (1) health care utilizations (eg, hospital length of stay, 90-day readmission rate, and incidence of nonhome discharge) and (2) 1-year PROMs between patients who received hypoallergenic and standard TKA implants.

METHODS

This was a retrospective review of prospectively collected data from patients who underwent primary TKA between 2018 and 2019. Propensity score matching (3:1) was used to compare standard TKA patients with those who received hypoallergenic TKA implants, respectively. Knee injury and Osteoarthritis Outcome Score (KOOS) pain, KOOS Physical function Shortform (PS), and Veterans RAND 12-Item Health Survey Mental Component Score were collected preoperatively and at 1-year. After matching, 190 hypoallergenic and 570 standard TKAs were analyzed.

RESULTS

No differences were observed in length of stay (P = .98), 90-day readmission (P = .89), and nonhome discharge (P = .82). Additionally, there was no significant difference in change from preoperative to 1-year PROMs (KOOS pain, P = .97; KOOS PS, P = .88; Veterans RAND 12-Item Health Survey Mental Component Score, P = .28). Patient-reported satisfaction was similar at 1-year (P = .23). Patients achieved similar rates of Patient Acceptable Symptom State (PASS) and minimal clinically important difference (MCID) for KOOS pain (PASS, P = .77; MCID, P = .33) and KOOS PS (PASS, P = .44; MCID, P = .65).

CONCLUSION

Patients treated with hypoallergenic TKA implants for suspected metal allergy had similar outcomes compared to patients who had standard implants and no metal allergy.

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.

Allergic reaction and metal hypersensitivity after shoulder joint replacement

PURPOSE

Metal ion release may cause local and systemic effects and induce hypersensitivity reactions. The aim of our study is first to determine if implant-related hypersensitivity correlates to patient symptoms or not; second, to assess the rate of hypersensitivity and allergies in shoulder arthroplasty.

METHODS

Forty patients with shoulder replacements performed between 2015 and 2017 were studied with minimum 2-year follow-up; no patient had prior metal implants. Each patient underwent radiographic and clinical evaluation using the Constant-Murley Score (CMS), 22 metal and cement haptens patch testing, serum and urine tests to evaluate 12 metals concentration, and a personal occupational medicine interview.

RESULTS

At follow-up (average 45 ± 10.7 months), the mean CMS was 76 ± 15.9; no clinical complications or radiographic signs of loosening were detected; two nickel sulfate (5%), 1 benzoyl peroxide (2.5%) and 1 potassium dichromate (2.5%) positive findings were found, but all these patients were asymptomatic. There was an increase in serum aluminum, urinary aluminum and urinary chromium levels of 1.74, 3.40 and 1.83 times the baseline, respectively. No significant difference in metal ion concentrations were found when patients were stratified according to gender, date of surgery, type of surgery, and type of implant.

CONCLUSIONS

Shoulder arthroplasty is a source of metal ion release and might act as a sensitizing exposure. However, patch test positivity does not seem to correlate to hypersensitivity cutaneous manifestations or poor clinical results. Laboratory data showed small constant ion release over time, regardless of gender, type of shoulder replacement and implant used.

LEVELS OF EVIDENCE

Level II.

Metal allergy in total-joint arthroplasty: Case report and literature review

RATIONALE

Due to the low incidence and lack of effective diagnostic measures for the diagnosis of metal allergy in patients undergoing total joint arthroplasty (TJA), diagnosis relies mainly on the exclusion of other causes, in particular infection. It remains a relatively unpredictable and poorly understood cause of implant failure. At present, skin patch testing, leukocyte migration inhibition test (LMIT) and lymphocyte transformation tests (LTT) are being commonly used to assess metal hypersensitivity.This report presents both a case and literature review.

PATIENT CONCERNS

A 61-year-old female patient experienced continuous swelling and pain in the right knee joint for 9 months after a right-side total knee arthroplasty (TKA).

DIAGNOSES

We believe this is the case report of metal allergy in TKA. The following were the reasons for this. First, no definite symptoms of infection during revision arthroplasty were observed, but with obvious hyperplasia of synovium. Furthermore, a frozen biopsy revealed an extremely low neutrophil count, which was considered to be caused by chronic inflammation. Second, the results of repeated post-operation reexaminations indicate a clear increase in the number of eosinophils, while no bacteria were found in the tissue bacterial smear performed during the operation. Third, improvements were clearly observed in the patient following synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment.

INTERVENTIONS

The patient underwent synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment.

OUTCOMES

The patient's right knee remained mildly swollen; however, the pain has been relieved significantly. The range of motion could achieve 0 degrees of extension and 90 degrees of flexion.

LESSONS

No consensus has been reached about the best diagnostic criteria for this disease, and most physicians would consider it to be a possibility when other diseases including periprosthetic joint infection (PJI) have been excluded. Although this case followed the same course, the outcome following synovectomy and anti-anaphylactic treatment further confirmed our hypothesis.

Surgical Treatment of Tattoo Complications

With a continuing increase in the number of tattoos performed worldwide, the need to treat tattoo complications is growing. Earlier treatments of chronic inflammatory tattoo reactions were dominated by a medical approach, or with no active intervention. In this chapter, we will address modern surgical approaches applied to situations when medical treatment is inefficient and lasers are not applicable. Dermatome shaving is positioned as first-line treatment of allergic tattoo reactions and also indicated in a number of other tattoo reactions, supplemented with excision in selected cases. The methods allow fundamental treatment with removal of the culprit pigment from the dermis. The different instruments, surgical methods, and treatment schedules are reviewed, and a guide to surgeons is presented. Postoperative treatments and the long-term outcomes are described in detail. An algorithm on specialist treatment and follow-up of tattoo reactions, which can be practiced in other countries, is presented.

Aseptic polyurethane carotid patch rejection: complication, allergy or miraculous healing?

Carotid endarterectomy plays an important role in the prevention of ischemic stroke; patching could reduce the risk of intra- and postoperative complications and late restenosis among primary closure. Materials actually available for the patch tailoring are synthetic or biological: which is the best is still debated. We present the case of a polyurethane (PU) carotid patch rejection three years after its implant, with no evident arterial discontinuity and no sign of infection. Histopathological analysis on hematoxylin-eosin stained sections of the regenerated arterial wall tissue removed revealed plasma cell infiltration and clusters of foreign body giant cells. PU patch rejection has been seldom described in literature. This is an unusual late complication that should be considered at long-term follow-up evaluation of these patients.

[Presentation and management of allergic fungal rhinosinusitis]

OBJECTIVE

To assess the presentation of allergic fungal rhinosinusitis (AFRS) and describe the line of management in our setup.

METHOD

Twenty-six cases of AFRS from October 2002 to June 2006 were retrospectively analyzed for the study in Department of Otorhinolaryngology Head and Neck Surgery, Peking University First Hospital. Laboratory findings (especially total serum IgE level and special serum IgE level) and computed tomography were noted preoperation. Surgical specimens were sent for mycology and histopathologic analysis. The management included endoscopic sinus debridement, adequate sinus aeration, pre- and post-operative use of steroids and saline irrigations with antifungal drugs.

RESULT

Nasal obstruction and hyposmia were the commonest presentations. In 21 (80.8%) of 26 patients, AFRS was fund to be associated with allergic diseases. CT scan showed serpiginous or patchy increased attenuation within the completely opacified sinuses on reconstructed soft tissue window. Some of the involved sinuses had bone erosion and expansion. 84.6% (22/26) patients had elevated total IgE levels, 76.9% (20/26) had positive for sIgE levels to fungal allergen. Fungal smear were positive for all 26 patients. But only 14 surgical specimens were positive for fungal cultures. The most common causative agent was Aspergillus. The involved mucosa and allergic mucin with H & E staining contained clusters or sheets of degenerating eosinophils. Charcot-Leyden crystals was found in 8 surgical specimens. The follow-up after a year, the mucosa recovered epithelization in 19 patients.

CONCLUSION

The diagnosis of AFRS required to depend on history, CT scanning, histopathology, mycologic and immunologic monitoring. Comprehensive treatment with endoscopic sinus surgery, steroids and saline irrigations with antifungal drugs is effective method.

Case report: local allergic reaction of bowel wall secondary to ruptured hydatid cyst

This is a report of a case of local allergic reaction which developed secondary to a ruptured hydatid cyst with a diffuse bowel thickening detected by computed tomography.

Orthopedic metal immune hypersensitivity

For many patients, the metals used in contemporary joint replacement surgery produce little or no reaction from the immune system. In a small but significant percentage of patients, however, a very rapid, T cell-mediated, allergic response may occur. If untreated, this reaction may ultimately lead to implant failure. Diagnosis may be complicated, and no effective treatments are available. Fortunately, alternative materials show great promise.

Resurfacing knee arthroplasty in patients with allergic sensitivity to metals

BACKGROUND

The problem of metal sensitivity (Ni, Cr, and Co) in arthroplasty is still unsolved. To prevent the risk of allergy in cases with proved metal allergy in an epicutaneous test, a Natural Knee total knee arthroplasty, made totally from titanium (Ti-6Al-4V) and polyethylene, can be implanted. The results of this device have to be compared to the results of normal knee arthroplasty designed with a femoral component out of CrCoNi alloy. The mechanical resistance of this alloy is much higher than that of titanium, and therefore it is the standard for the femoral components of most knee-resurfacing devices.

METHODS

Thirty-five patients with a titanium Natural Knee were examined retrospectively after a mean follow-up of 2 years and 5 months (range 6 months to 5 years and 4 months). In comparison, 36 patients with a Genesis-I knee with a CrCoNi alloy femoral component were studied after a mean follow-up of 2 years and 4 months (range 8 months to 6 years and 2 months).

RESULTS

In spite of the lower mechanical resistance of titanium, the Natural Knee showed better results (knee score 84.1 points, function score 77.7 points, HSS score 80.1 points, 82.9% excellent and good results) than the Genesis-I knee (knee score 80.6 points, function score 76.4 points, HSS score 76.4 points, 68.5% excellent and good results), although these differences had no statistical significance.

CONCLUSIONS

The titanium Natural Knee prosthesis has proven to be a reliable knee joint replacement in the medium term.

Adult-onset otitis media with effusion: results following ventilation tube insertion

The outcome of otitis media with effusion (OME) in children is generally good. However, it is less clear in adults. All adult patients who had a ventilation tube inserted for OME at the Ipswich Hospital between 1996 and 1997 were studied. Of 53 patients studied, 28 had had a previous history of ventilation tube insertion. Furthermore, at 15-27 months following ventilation tube insertion, the ventilation tube had already extruded in 31 patients and the OME had already recurred in 19 of these. Endoscopic examination revealed that many patients still had evidence of inflammation at the lateral nasal wall (26.4 per cent) and at the eustachian tube orifice (51 per cent). There is also a strong history of atopy in the studied group and the skin prick test was positive in 57 per cent of the patients. This study shows that many patients with adult-onset OME have underlying pathology that could lead to recurrence of OME following ventilation tube extrusion.

[Prospective study of the significance of contact sensitization caused by metal implants]

INTRODUCTION

Allergies caused by metallic implants are often thought to be a reason for postoperative complications like bone necrosis or loosening of the prosthesis.

PATIENTS AND METHODS

In a prospective study, we investigated allergic sensitivity against components of stainless steel implants, including titanium, in 112 patients shortly before surgical operation. The same tests were then repeated in 100 of these patients exactly one year after operation. There were three different kinds of procedures: 1. titanium implants, mainly total hip replacements, 2. regular steel implants, 3. surgery without any implants (control group). Any differences from the process of regular healing were regarded as postoperative complications.

RESULTS

A sensitivity against nickel (Ni) was diagnosed in three of these 100 patients (3%) before surgery. These patients, of whom two received a nickel-containing implant and one a titanium arthroplasty, did not show any postsurgical complications. Furthermore, three patients (3%) acquired a new sensitivity against metals during the study-interval of one year. Two of these three patients were women, who developed a postsurgical sensitivity against nickel or chrome but got titanium arthroplasties, which did not contain any nickel. These two women wore metal-containing jewelry, which might be the reason for the newly acquired metal-sensitivities, and both showed postsurgical complications. The third patient, who has developed a postsurgical sensitivity against components of his steel arthroplasty, did not reveal any complications.

DISCUSSION

We conclude that the rate of allergic sensitization against metal-components of arthroplasties is low in our patients. Additionally, skin-sensitivity against components of alloys and platings was not associated with a higher rate of postsurgical complications in our patients. We did not see any sensitivity against titanium. In conclusion, metallic implants are not a cause of allergies to a relevant extent, nowadays.

Unilateral tonsillectomy--indications and results

Seventy-six cases of unilateral tonsillectomy performed over the last 20 years are reported. The average age was 3.75 years. Fifty per cent had adenoidectomy. A review of their case notes and of 54 questionnaires returned by parents, asking their opinion of the change in symptoms before operation and two years after operation, showed that they could be allotted into three groups: Group 1 35 cases (65 per cent) had dramatic improvement in the symptoms of allergy, colds, otitis, sore throats, eating, meat eating and sleep. Group 2 of nine cases (17 per cent) had considerable improvement in most symptoms. Group 3 of 10 cases (18 per cent) had minimal improvement. Post-tonsillectomy hypertrophy of the remaining tonsil occurred within two to four years in nine cases, necessitating removal. Four (11 per cent) in Group 1, (22 per cent) in Group 2, and three (30 per cent) in Group 3. The three secondary tonsillectomies in Group 3 gave good results in two cases. In five cases the other tonsil was removed six to 15 years later. This series of cases has demonstrated that a tremendous decrease in incidence of throat and upper respiratory tract infection in young children, apparently prone to infection can occur in over 80 per cent of cases following unilateral tonsillectomy, in spite of the continued presence of the remaining large tonsil.(ABSTRACT TRUNCATED AT 250 WORDS)