Nicholas M Brown, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Mid-America Orthopaedic AssociationDisclosure: Nothing to disclose. Bone alternatives like calcium phosphate may cause fever. [61] as compared with other modes of failure. Hypersensitivity reactions to metal implants: laboratory options. Traditionally, skin patch testing has been the standard screening test for metal hypersensitivity; it is cost-effective and technically simple. Usually, rose gold and yellow gold doesnt contain nickel. [1, 3] Cardiac stents and patches are made of nitinol (an alloy of titanium and nickel). [3] M1 proinflammatory macrophages arrive as part of the initial inflammatory response WebCan surgical hardware rejection symptoms? It may also be done when the hardware causes allergy or bone fracture. Macrophage responses to implants: prospects for personalized medicine. Correlation of MARS MRI findings with cup position, metal ion levels and function in metal-on-metal total hip arthroplasty. Contact Dermatitis. WebCan surgical hardware rejection symptoms? [QxMD MEDLINE Link]. 2017. [4] High chromium ion concentrations may be carcinogenic, and high cobalt ion concentrations may be both cardiotoxic and neurotoxic. [81] ; thus, the lymphokine MIF result couldbe negative in osteolysis. Merritt K, Rodrigo JJ. The patient underwent a left THA with the use of a cementless titanium implant with a ceramic head (see the first image below). At the first site (right hip), complete healing occurred, and the patient remained asymptomatic after the device was removed. Fujishiro T, Moojen DJ, Kobayashi N, Dhert WJ, Bauer TW. Both involve a robust intra-articular immune response; however, metal reaction shows predominance of perivascular lymphocytes, plasma cells, and macrophages, whereas infection is characterized by an abundance of neutrophils on biopsy. [6, 83], The usual course of events in patients demonstrating true postimplantation metal hypersensitivity is such that symptoms develop over months to years; this may be long after the device has accomplished the goal of fracture stability. 17 (1):486. Cell culture methods for testing biocompatibility. [2], Surface charge changes the immune response. Patients that have previously had surgery to fix a fracture or to fuse a bone of the foot and ankle may have retained hardware that can become prominent and/or creates discomfort. Generalized sensitivity from an implanted orthopaedic antibiotic minichain containing nickel. Antibacterial surface treatment for orthopaedic implants. Metal screws and plates are often used in surgery to fix fractures, fuse joints, or stabilize bones that have been cut (osteotomies) in the foot and ankle. [QxMD MEDLINE Link]. 2015:910156. Sensitivity to metal as a possible cause of sterile loosening after cobalt-chromium total hip-replacement arthroplasty. The symptoms are always individual. Clin Orthop Relat Res. This patient received three different stainless steel devices at two different sites. Koutalos et al found a correlation between patients with adverse reactions to metal debris (ARMD) and prosthesis cup position but no correlation with metal ion levels. [44], Implanted pulse generators (eg, pacemakers, gastric stimulators, and neurostimulators) are made with stainless steel, titanium alloy, platinum, and iridium but also with epoxy resins, polymethylmethacrylates (PMMAs), and isocyanates, all of which may be immunogenic in some patients. Case example. How can I test myself for nickel allergy? [39] Nevertheless, they are commonly performed in the workup to rule out infection as the cause of the prosthesis failure. What are the symptoms of titanium allergy? Cha c sn phm trong gi hng. Options for surgical treatment include the following: Revision joint replacement surgery in patients with metal-on-metal prostheses have worse outcomes with more complications when the revision is due to metal reactions Anionic/neutral particles decrease inflammatory reactions, whereas cations increase inflammation. Whittingham-Jones PM, Dunstan E, Altaf H, Cannon SR, Revell PA, Briggs TW. Nonetheless, careful radiographic assessment of the implant is required. Patients with intolerance reactions to total knee replacement: combined assessment of allergy diagnostics, periprosthetic histology, and peri-implant cytokine expression pattern. hardware BMC Musculoskelet Disord. 2014. X-rays will reveal the hardware if it is metal (most screws are The immune system modulates the osteoclastogenic process via three main cytokines, as follows: An increased RANKL-to-OPG ratio leads to enhanced osteoclast activity, accelerated bone resorption, and excessive bone loss. At 4-year follow-up, she had no further complaints or problems (see the second image below). [3] Larger pores decrease inflammation. Please confirm that you would like to log out of Medscape. [52], Dendritic cells control immune responses against implanted materials. [QxMD MEDLINE Link]. [82], Implant properties may alter the amount of surface area available for metal ion release. It is likely that she did have a true metal sensitivity reaction causing clinical failure of hardware and disabling pain. [QxMD MEDLINE Link]. Clin Orthop Relat Res. The problem in total joint arthroplasty: aseptic loosening. However, some metals (including cobalt) can cause soft-tissue inflammation via direct toxicity of the metal ions without the hypersensitivity response. Evaluation and management of metal hypersensitivity in total joint arthroplasty: a systematic review. 2014. Painful Hardware is a possible side effect from metal screws and plates, which are often used in surgery to fix fractures, fuse joints, or stabilize bones. The State of the Art and Prospects for Osteoimmunomodulatory Biomaterials. [QxMD MEDLINE Link]. Biomaterials. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. 2020 Jan. 17 (1):41-56. [29, 4]. Signs and symptoms include an itchy rash with redness, swelling, scaling and possibly a crusty appearance. Metal Allergy to Surgical Plates, Screws, and Implants 1980 Feb. 51 (1):57-62. This approach could be used as an adjunct to routine patch testing. [4] Workup may be indicated before surgery for joint replacement patients with a history of skin reactions to metal jewelry, jean snaps, watch bands, metal glass frames, artificial nails, or skin glue. Researchers at National Jewish Health have developed a nickel lymphocyte proliferation test [1]. The film has a strong inhibitory effect on the production of inflammatory cytokines released by macrophages Some people report instability or feeling like their hip is going to give out. Metal sensitivity in patients undergoing hip replacement. 49 (Pt 2):118-31. Can a minor go to Mexico without a parent? [63] as a rule, testing can be considered in patients with known hypersensitivity reactions. Although prescreening all patients for metal hypersensitivity may be costly and its clinical relevance dubious, various specific laboratory tests, including the lymphokine migration inhibition factor (MIF) test, appear to be confirmatory. sores and swelling in the soft tissues of the mouth. Biomaterials. I had spinal fusion 7/30. My incision burst open, was on a wound vac for 8 weeks but wouldn't heal, had second surgery to clean and close the wound For many implants, this can be done under regional or local anesthesia (i.e., a nerve block), which means that you can stay awake (if you want) for the procedure and not feel anything. [2, 3] and decrease macrophage adhesion, thus enhancing osseointegration. Intraoperative cultures were obtained that all proved negative for an infectious cause. Metal sensitivity reactions to orthopedic implants. [2, 49]. 2011 Apr. Also, the results depend on the experience of the person visually reading the skin reaction and may be influenced by medications, the quality of the antigens chosen, and the time of reading. 2015 Dec. 98 (6):953-62. [4] Nonmetallic materials can be organic or inorganic. The barometric pressure drops when storms are rolling in, and somehow, the body detects this change, causing swelling of soft tissue or expanding of joint fluid. Symptoms of infected stitches. 2008 Apr. William J Hopkinson, MD, FACS, FAAOS Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Chief of Joint Replacement Service, Department of Orthopedic Surgery, Loyola University Medical Center The results demonstrated increased uptake and lucency around the lag screw, indicative of hardware loosening. Many of the same peri-operative risks apply for hardware removal, as for any surgical procedure. Perivascular and diffuse lymphocytic inflammation are not specific for failed metal-on-metal hip implants. Occasionally prominent, non-absorbent sutures or other forms of retained surgical material may create symptoms but may not show up on x-rays. Corrosion and Degradation of Implanted Materials: Second Symposium. Adv Healthc Mater. Rheumatol Ther. Activated platelets stimulate migration of monocytes, which differentiate into macrophages. Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee SurgeonsDisclosure: Nothing to disclose. Xie Y, Hu C, Feng Y, Li D, Ai T, Huang Y, et al. At day 6, 3H-thymidine uptake is measured by using liquid scintillation. Swiontkowski MF, Agel J, Schwappach J, McNair P, Welch M. Cutaneous metal sensitivity in patients with orthopaedic injuries. 8th ed. 1990 Nov. 23 (5):378-9. 2001 Feb. 15 (2):86-9. [68, 69, 70, 71, 72, 73] The technical sophistication and high expense of the LTT for implant-related metal sensitivity has limited its use; therefore, few conclusions can be drawn. 1986 Apr. The clinical presentation of patients with metal implant reactions is often nonspecific. Hypersensitivity Reactions to Implanted Metal Devices: Facts and Fictions. Computed tomography (CT) is not sensitive for diagnosing implant loosening but may help characterize the location and extent of the bone resorption when present. In a prospective cohort study that included 597 patients with metal-on-metal hip resurfacing and total hip prostheses, Hart et al found that elevated blood levels of metal (ie, chromium and cobalt) ions were associated with an increased risk of implant failure. Preoperative skin patch testing is not typically recommended unless there is a strong suggestion of established sensitivity by history, because of the slight chance of sensitization and the high-cost/low-yield results expected. [3] As stated by Alobaid et al, "[t]he ability to suppress adverse immune responses and promote beneficiary regulatory and pro-healing immune responses will improve the clinical outcome for implanted materials whether used as scaffolds for regenerative medicine applications or in medical devices." Koutalos AA, Toms AP, Cahir JG, Smith EJ. Hallab NJ, Caicedo M, Finnegan A, Jacobs JJ. If you log out, you will be required to enter your username and password the next time you visit. Some research suggests that metal medical and dental implants may cause an autoimmune reaction in people with metal allergies and other genetic predispositions. What Is the Clinical Presentation of Adverse Local Tissue Reaction in Metal-on-metal Hip Arthroplasty? Prevalence of contact allergy by sex, race and age. Patients can present with localized dermatitis Acta Biomater. Evaluation of several immunological parameters in patients with aseptic loosening of hip arthroplasty. Infected Stitches J Bone Joint Surg Br. [Full Text]. There may be a bursa (fluid filled sac of tissue) or an area of inflammation associated with the area. [63]. [QxMD MEDLINE Link]. These coating substances can encourage attachment of host cells and a local immune response against the infectious organism Trans Soc Biomaterials. Int J Nanomedicine. [79], Another in-vitro test that has shown promise in diagnosing metal hypersensitivity involves the use of MIF. [2, 3] which include the following: Previous strategies to avoid the negative results of the immune response to implants primarily involved hiding the implant from the immune system by using relatively inert or biocompatible implants to prevent or mitigate the negative aspects of chronic inflammation. National Jewish Health. Vol 1: 565-74. Lachiewicz PF, Watters TS, Jacobs JJ. [3] : Surface topography can stimulate immune cell functions in such a way as to provide a favorable osteoimmune environment for bone incorporation. Huber M, Reinisch G, Trettenhahn G, Zweymller K, Lintner F. Presence of corrosion products and hypersensitivity-associated reactions in periprosthetic tissue after aseptic loosening of total hip replacements with metal bearing surfaces. Metal allergy was found with severe types of alopecia areata (AA) at the rate of 69.9% and the elimination of metal allergens from dental metals, cooking instruments lead to satisfactory hair regrowth and prevention of severe relapse of AA for the period of in average four years and four months at the rate of 75.5%. [Full Text]. Pain when you first get up to walk can also be a concern. [QxMD MEDLINE Link]. Kzhyshkowska J, Gudima A, Riabov V, Dollinger C, Lavalle P, Vrana NE. [QxMD MEDLINE Link]. Demoly P, Michel F, Bousquet J. [2] According to Huber et al, the presence of corrosion products and a hypersensitivity reaction in patients suggests that there is a relation between corrosion and implant-related hypersensitivity. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Panigutti MA, Merritt K, Bruner RJ, et al. Should Your Spinal Hardware Be Removed? Heres How to Tell The septic joint near the implanted hardware. 2016 Jun 13. For example, the nickel content in stainless steel may vary in the range of 9-15.5%, whereas in cobalt-base alloys, the nickel content is usually specified to be no greater than 1% (< 0.2% in actual practice), and titanium content is essentially 0%. Symptoms of a loose hip replacement include pain in the groin or upper thigh, new popping or clicking noises, joint instability, and dislocation or subluxation (partial dislocation) of the joint. Contact Dermatitis. [QxMD MEDLINE Link]. 2016 Nov 23. Pacheco KA. Sampson B, Hart A. Once the more common causes of implant failure have been excluded, the possibility of allergic reaction to the metal must be considered, evaluated, and treated. An infection can occasionally be the cause of pain as well, so your surgeon will evaluate patients for this potential problem. McGough RL III, McMahon PH. Contact Dermatitis. Albrektsson T, Becker W, Coli P, Jemt T, Mlne J, Sennerby L. Bone loss around oral and orthopedic implants: An immunologically based condition. [4] Preoperative aspiration of synovical fluid for culture, cell count, and neutrophil percentage may also be included in the workup to rule out infection. Surgical-grade stainless steel may contain some nickel, but its generally considered hypoallergenic for most people. Metal Hypersensitivity and Total Knee Arthroplasty. Patch testers' opinions regarding diagnostic criteria for metal hypersensitivity reactions to metallic implants. However, because such a reaction is a diagnosis of exclusion, definitive proof is difficult to achieve. Skin patch testing may therefore be unreliable. 1979 Jan. 5 (1):27-32. Response profiles of circulating leukocytes and metal ions in patients with a modular dual-mobility hip implant. [QxMD MEDLINE Link]. Prospective studies of patients who had positive skin patch test results showed no difference in reoperation rates as compared with patients who had negative skin patch test results. McMahon PH, Skinner HB, eds. The key to success is to design implants with biomaterials that modulate the local immune environment from proinflammatory to healing. The presentation may include dermatitis and skin reactions, joint pain, joint effusions, and decreased wound healing. Another important factor to consider in the biologic response to orthopedic implants is metal ion exposure and release. Osteolysis and aseptic loosening should always be included in the differential diagnosis. A review of the literature and report of three cases. Human primary macrophages exposed to the implantable materials ex vivo might allow prediction of an individual's reactions and in the future allow specific selection of an optimal coating composition for that individual patient to prevent or control the immune response to the implant.