Diagnostic dilemmas of Titanium Hypersensitivity in patients with medical implants: a case series. However, the clinical significance of the allergy is controversial. Second stainless steel implant in the patient's right hip. When implants degrade or corrode, the immune system also responds to surface changes and degradation products. [3] IL-10 is an anti-inflammatory cytokine that has a significant role in maintaining immune homeostasis and resolving inflammation. In the meantime, the orthopedic surgeon must be aware of the potential problem but should exercise caution in making the diagnosis. A skin rash may develop over the metal device but is not always present. Contact with blood activates the coagulation systems, the complement system, platelets, and immune cells, resulting in a thrombus at the interface that is the transient provisional matrix. The symptoms can often be reproduced with motion of the joint or movement of nearby tendons. Merritt K, Rodrigo JJ. 6th ed. 24 (1):37-44. [50], The switch from M1 to M2 is regulated by immune cells, including T cells of various subsets, cytokines, and microRNAs (miRNAs). [4] The metals most commonly used in orthopedic and dental implants are stainless steel (with nickel), cobalt, chromium, and titanium. The addition of specific cytokine tests (eg, Luminex cytokine assays) may more accurately reveal the qualitative and quantitive involvement of different cell types. Immunomodulation with Self-Crosslinked Polyelectrolyte Multilayer-Based Coatings. Carando S, Cannas M, Rossi P, Portigliatti-Barbos M. The lymphocytic transformation test (L.T.T.) [52]. 2008 Feb 13. [49, 86] while promoting the release of anti-inflammatory cytokines. [52], Dendritic cells control immune responses against implanted materials. 2021 Dec. 24 (8):1307-1316. [40] This serves as a screening test for the possible presence of asymptomatic local soft-tissue reaction. Brown SA, Merritt K, Mayor MB. [4, 63] Thus, many people who have skin reactivity to metals may never develop any reactivity at the site of a prosthesis composed of that metal. Sensitivity to implant materials in patients with total knee arthroplasties. 2015:910156. 2021 Sep 1. Biomacromolecules. [QxMD MEDLINE Link]. Veien NK, Svejgaard E, Menn T. In vitro lymphocyte transformation to nickel: a study of nickel-sensitive patients before and after epicutaneous and oral challenge with nickel. [60]. 4 (5993):376-8. 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. [QxMD MEDLINE Link]. Wawrzynski J, Gil JA, Goodman AD, Waryasz GR. [3] Although technically metals, metal ions are often also included under the immune response to nonmetal implants. Composition of common metal alloys used in orthopedic implants. Adv Healthc Mater. St Louis: Mosby-Year Book; 1998. Acta Derm Venereol. She was recovering well with signs of fracture healing until 3 months after surgery, when she began to experience pain over the implanted hardware. [5] It therefore is not surprising that immune response to medical implants is commonly reported in the literature, including hypersensitivity to pacemakers or other cardiovascular devices, endovascular stents and coils, dental implants, and orthopedic hardware (eg, joint replacement prostheses, fracture fixation devices, and pain-relief stimulators). 58 (3):245-50. Usually, the M1 macrophages transform into M2 macrophages, which help regulate tissue remodeling. 17 (1):486. [34, 35] Metal sensitivity may also be associated with chronic fatigue syndrome, fibromyalgia, and autoimmune syndromes. An immune response can develop against nonmetallic components of implants as well. [63] as a rule, testing can be considered in patients with known hypersensitivity reactions. Peltonen L. Nickel sensitivity in the general population. Lymphocyte transformation in vitro in dermatophytosis. [1], The American Contact Dermatitis Society has suggested testing before device implantation in patients with a clear history of metal reactions. Metal ion release may also be due to surgical technique in patients with metal-on-metal prostheses. J Clin Invest. Wear particles, periprosthetic osteolysis and the immune system. Are children of working mothers more successful? [2] For example, osteoblast migration and proliferation are promoted by transforming growth factors (eg, TGF-) and interleukins (eg, IL-4) but inhibited by tumor necrosis factors (eg, TNF-) and other interleukins (eg, IL-1). [3] M1 proinflammatory macrophages arrive as part of the initial inflammatory response An MRI Study. Computed tomography (CT) is not sensitive for diagnosing implant loosening but may help characterize the location and extent of the bone resorption when present. The effects of metal corrosion debris on immune system cells. Blom LH, Elrefaii SA, Zachariae C, Thyssen JP, Poulsen LK, Johansen JD. Why Do Cross Country Runners Have Skinny Legs? [QxMD MEDLINE Link]. In a study including 11 cases where periprosthetic tissue contained corrosive elements (solid chromium orthophosphate corrosion products) after aseptic loosening of articular implants, immune-response tissue reactions were identified in every case. 2008 Apr. Patch testers' opinions regarding diagnostic criteria for metal hypersensitivity reactions to metallic implants. Surgically implanted devices, prostheses, grafts, and fixation materials are commonly used for joint replacement, correction of spinal pathology, repair of fractures, treatment of cardiovascular pathology, and control of chronic pain. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTIzMDY5Ni1vdmVydmlldw==, Macrophage colony-stimulating factor (M-CSF), Receptor activator of NF-B ligand (RANKL). [2, 3] Titanium oxide nanotube structures increase surface area, thereby improving macrophage adhesion. [QxMD MEDLINE Link]. Patients can present with localized dermatitis Image shows the failed stainless steel implant in the patient's left hip. 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. In most instances, these screws and plates do not create symptomsand remain permanently in the foot. Eltit F, Noble J, Sharma M, Benam N, Haegert A, Bell RH, et al. [QxMD MEDLINE Link]. 59 (2):164-8. Current Diagnosis and Treatment in Orthopaedics. The symptoms are always individual. 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. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. 1991 Feb. 62 (1):29-32. Given the false-positive results of skin patch testing, blood samples were sent for MIF testing, which later confirmed nickel hypersensitivity (personal communication, Katharine Merritt, PhD, US Food and Drug Administration Office of Science and Technology). [63], Phase-contrast and laser scan confocal microscopy (LSCM) is another method of quantifying the number of positive cells involved in the immune reaction. [QxMD MEDLINE Link]. 2012 Jun. ASTM STP 1144. 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. 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%. Schalock PC, Thyssen JP. Chir Organi Mov. [61]. TimesMojo is a social question-and-answer website where you can get all the answers to your questions. These peptides are biocompatible with macrophages and neutrophils. Teo Wendy ZW, Schalock PC. While the potential for a reaction exists, its thought to be extremely rare. Unusual skin cancer linked to chronic allergy from metal orthopedic 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. The patient had positive nickel sensitivity, as shown on both skin patch testing and lymphokine MIF testing, and negative culture results with no clinical evidence of infection. Irrigation and debridement were performed, and the patient was treated with intravenous antibiotics until intraoperative cultures proved negative. The results were positive for an allergy to nickel sulfate (with >20 mm of erythema noted) but negative for chromium and cobalt. 2001 Feb. 15 (2):86-9. How do you know if your spouse is not happy? 2012 Mar. Metal ion release after total hip replacement. [10, 18, 21] others have argued that even if a metal allergy exists, no adverse effects occur. Do Men Still Wear Button Holes At Weddings? Lymphocyte transformation induced by nickel sulphate: an in vitro study of subjects with and without a positive nickel patch test. An infection can occasionally be the cause of pain as well, so your surgeon will evaluate patients for this potential problem. Available at https://www.sciencedaily.com/releases/2014/10/141009153817.htm. Acta Derm Venereol. Thomas P, von der Helm C, Schopf C, Mazoochian F, Frommelt L, Gollwitzer H, et al. [1]. When a hydrophilic surface is combined with a rough surface topography, there is a synergistic effect that yields even greater release of anti-inflammatory cytokines. EMMY NOMINATIONS 2022: Outstanding Limited Or Anthology Series, EMMY NOMINATIONS 2022: Outstanding Lead Actress In A Comedy Series, EMMY NOMINATIONS 2022: Outstanding Supporting Actor In A Comedy Series, EMMY NOMINATIONS 2022: Outstanding Lead Actress In A Limited Or Anthology Series Or Movie, EMMY NOMINATIONS 2022: Outstanding Lead Actor In A Limited Or Anthology Series Or Movie. Symptoms of infected stitches. The lymphocytes are then mixed with solutions of specific metal ions, such as nickel, chromium, cobalt, or titanium. Metal hypersensitivity is a common immune disorder. Four years later, the patient had an intertrochanteric fracture of the contralateral left hip and again underwent ORIF with a stainless steel device (Synthes DHS) (see the image below). [QxMD MEDLINE Link]. What kind of metal do they put in your body? Hydrophilic materials are protein-resistant Osteolysis and aseptic loosening should always be included in the differential diagnosis. The clinical presentation of patients with metal implant reactions is often nonspecific. This can cause numbness, tingling, or pain. 131:581-594. body [79], Another in-vitro test that has shown promise in diagnosing metal hypersensitivity involves the use of MIF. Again, 4 months postoperatively, the patient began to complain of similar right hip pain, though imaging showed good bone graft incorporation and fracture healing (see the image below). Applying diagnostic criteria may be useful in guiding the decision making process when faced with symptomatic or failing devices. J Arthroplasty. Ital J Orthop Traumatol. Hardware removal should be considered if there are any skin issues or signs of infection.

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